Intervention to improve kinesiophobia in patients with coronary artery disease: a systematic review and meta-analysis of randomized controlled trials

Abstract

Aim

To describe interventions aimed at improving kinesiophobia in patients with coronary artery disease and provide an estimate of their effectiveness.

Method

A systematic review was conducted from 10 databases including PubMed, Web of Science, Cochrane Library, CINAHL, Embase, APA-PsycInfo, CNKI, VIP, Sinomed, and WangFang to identify all randomized controlled trials that were published from the time of database creation through August 2024. Quality assessment and data extraction were performed independently by two researchers. Using the Cochrane Risk of Bias Assessment Tool for quality assessment and RevMan 5.4 and Stata 15.0 for data syntheses. Subgroup analysis, sensitivity analysis, and publication bias were also conducted.

Design

A systematic review and meta-analysis of randomized controlled trials.

Result

A total of 16 randomized controlled trials (N = 1408) were included. Interventions to improve kinesiophobia in patients with coronary artery disease include cognitive behavioral interventions, psychological interventions, exercise interventions, multi-modal combined interventions, online and offline of home rehabilitation, and Preoperative Physical Therapy, and all interventions were effective(P < 0.01).These interventions were statistically significant at 1–2 months(SMD=-1.75; 95% CI=-2.16, -1.34), 3 months(SMD=-2.04; 95% CI=-2.66, -1.42), and 6 months(SMD = -4.90; 95% CI = -7.59, -2.20), there was no difference in kinesiophobia between 1 and 3 months after the intervention. These Interventions to reduce patients’ kinesiophobia can also promote the overall improvement of psychological status, cardiac function, exercise capacity, and quality of life(P < 0.01). Although publication bias was detected, sensitivity analyses confirmed the robustness of pooled results.

Conclusion

Six intervention modalities identified across 16 included studies were effective in reducing kinesiophobia and demonstrated beneficial short- to mid-term effects. Early identification and intervention targeting kinesiophobia may improve psychological well-being and functional recovery. Further reduction may require individualized approaches and hybrid rehabilitation models combining tele- and center-based strategies. Future standardized, high-quality randomized controlled trials with extended follow-up are needed to clarify long-term effectiveness and support personalized rehabilitation strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-026-05812-x.

Introduction

Coronary artery disease (CAD) remains one of the leading causes of morbidity and mortality worldwide, particularly in low- and middle-income countries, accounting for an estimated 7 million deaths and 129 million disability-adjusted life years annually [1, 2]. Beyond its substantial mortality burden, CAD significantly impairs patients’ quality of life and daily functioning, contributing to long-term physical and psychosocial limitations [3, 4].

Cardiac rehabilitation (CR) is a comprehensive, medically supervised, multidisciplinary program aimed at improving cardiovascular health among individuals with heart disease. CR typically integrates structured exercise training, patient education on heart-healthy lifestyle behaviors, psychosocial counseling for stress management, and behavioral support to enhance long-term adherence [5]. The primary goals of CR include optimizing physical, psychological, and social functioning; reducing cardiovascular risk factors; improving health-related quality of life; and preventing recurrent cardiac events [6–8]. Among its core components, exercise training represents the cornerstone of CR and is supported by strong clinical evidence demonstrating improvements in cardiorespiratory fitness, reductions in recurrent cardiovascular events, and lower all-cause and cardiac-specific mortality [4, 9].

Despite these established benefits, many patients develop a fear that physical activity may trigger another cardiac event following an acute cardiovascular episode [10]. This fear often leads to avoidance of necessary rehabilitation activities, thereby limiting recovery and functional improvement [11, 12]. This condition, known as kinesiophobia, refers to an excessive and irrational fear of movement or physical activity stemming from concerns about pain, harm, or re-injury [13, 14].

Kinesiophobia is a prevalent psychological barrier among patients with CAD, with studies suggesting that up to 70% of this population experience varying levels of movement-related fear [10, 11, 15–17]. This fear-avoidance behavior contributes to physical deconditioning, heightened psychological distress, poorer adherence to CR programs, and overall deterioration in health-related quality of life [18, 19]. Addressing kinesiophobia is therefore essential to improving participation in exercise-based rehabilitation and optimizing long-term cardiovascular outcomes [20–22].

A range of interventions has been explored to reduce kinesiophobia in patients with CAD, including exercise-based CR, cognitive-behavioral therapy (CBT) to challenge maladaptive fear beliefs, exposure-based approaches involving gradual reintroduction to movement, and other psychological or behavioral interventions [23–25]. These strategies aim to reduce fear-avoidance behaviors, enhance engagement in rehabilitation, and promote sustainable improvements in cardiovascular health.

However, systematic evidence comparing the effectiveness of different intervention types specifically targeting kinesiophobia in patients with CAD remains limited. Additionally, the influence of intervention duration on treatment outcomes has not been comprehensively evaluated. Clarifying which interventions are most effective, and over what time frames, may inform clinical decision-making, optimize resource allocation, and reduce unnecessary healthcare burden.

Therefore, this systematic review aims to: (I) categorize interventions designed to reduce kinesiophobia in patients with CAD and evaluate their comparative effectiveness; (II) assess temporal effects by examining outcomes at 1–2 months, 3 months, and 6 months of follow-up; and (III) evaluate the multidimensional impact of these interventions on psychological status, cardiac function, quality of life, and exercise capacity in this population.

Method

The protocol for this review has been registered in the International Prospective Register for Systematic Reviews (PROSPERO; registration ID: CRD42024553303). This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [26].

Search strategy

The PubMed, Web of Science, Cochrane Library, CINAHL, Embase, APA PsycInfo, CNKI, VIP, SinoMed, and WangFang were searched from the establishment of the database until August 2024. Corresponding Chinese terms were used for searching in Chinese databases (Chinese National Knowledge Infrastructure). The search terms used were “Myocardial” OR “Coronary” OR “Cardi*” OR “heart” OR “chest pain” OR “Angina” OR “Percutaneous Coronary Intervention” OR “Coronary Artery Bypass” and “Kinesiophobia” OR “Pain-Related Activity Avoidance” OR “Activity Avoidance, Pain-Related” OR “Avoidance, Pain-Related Activity” OR “Pain Related Activity Avoidance” OR “Kinetophobia” OR “Fear of Movement” OR “Movement Fear” OR “Kinesophobia” OR “Movement Phobia” OR “Phobia, Movement” OR “kinesiophobia” OR “exercise fear” OR “sports fear” OR “sports phobia” OR “Exercise Sensitivity” OR “Fear Avoidance” OR “fear of Activity”. Clinical trial registries, including ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), were screened to identify potentially relevant studies. Detailed search strategies for each database are provided in Additional file 1.

Inclusion criteria and assessment

Studies were selected according to predefined Population, Intervention, Comparison, Outcome, and Study design (PICOS) criteria (Table 1). Studies that meet the following criteria are included in the review. Two authors (Lingqiao Gong, Panpan Xu) independently screened the titles and abstracts of all retrieved reports, retaining articles related to kinesiophobia in patients with CAD, then resolving disagreements based on the consensus with third author (Xue Chen). Databases in both English and Chinese were systematically searched to maximize the coverage of relevant studies, with no language restrictions applied. However, grey literature—such as conference abstracts, unpublished reports, and postgraduate theses—was not considered for inclusion. This decision was based on the generally lower methodological transparency and incomplete reporting of outcome measures often associated with such sources, which could compromise the reliability and comparability of data in the quantitative synthesis.

Table 1.

Inclusion and exclusion criteria

PICOS	Inclusion criteria	Exclusion criteria
Population	Adults diagnosed with coronary artery disease, including acute or chronic coronary syndrome, myocardial infarction, coronary artery bypass grafting, or percutaneous coronary intervention	Presence of other major comorbid diseases or cardiovascular conditions with complete exercise restriction
Intervention	Any nursing-led or nursing-involved intervention aimed at reducing kinesiophobia	No intervention
Comparison	Routine care or no intervention	Absence of a comparison group
Outcome	Kinesiophobia assessed using any version of the Tampa Scale of Kinesiophobia	Studies not using the Tampa Scale of Kinesiophobia
Study design	Randomized controlled trials (RCTs)	Non-randomized controlled trials or cohort studies
Language	No language restrictions	—
Publication type	Peer-reviewed journal articles	Grey literature, including conference abstracts, unpublished reports, and postgraduate theses

Data extraction and quality assessment

Data extraction and quality assessment were carried out independently by two authors (Lingqiao Gong, Panpan Xu), including researcher characteristics (author’s name, country, year of publication, type of CAD, setting), participants (sample size, age, gender), interventions, and outcomes (assessment tools, duration of follow-up).

The risk of bias of included randomized controlled trials (RCTs) was assessed using the Cochrane Risk of Bias tool version 2 (RoB 2) [27], which evaluates six domains: bias arising from the randomization process, deviations from intended interventions, missing outcome data, outcome measurement, selection of the reported result, and other potential sources of bias. Each domain was rated as low risk, some concerns, or high risk. Discrepancies were resolved through discussion or consultation with a third reviewer (Xue Chen).

Data synthesis and analysis

Statistical analyses were performed using RevMan 5.4 and Stata 15.0 to extract the mean (M) and standard deviation (SD) of each outcome in each study. Data pooling occurred when at least three studies reported the same outcome indicator. In addition, when articles provided standard error (SE), sample size (n), and 95% confidence interval (95%CIs), we calculated mean (M), standard deviation (SD) or standardized MD (SMD) accordingly.

Subgroup analysis was performed according to intervention type and intervention duration. Interventions were assessed validity for psychological function, cardiac function, quality of life, and exercise capacity. I-squared statistic (I²) was used to assess heterogeneity, and data were combined using a random-effects model if I² >50% and P < 0.10, otherwise, a fixed-effects model was used. I² values of 0%–40%, 30%–60%, 50%–90% and 75%–100% indicated not important, moderate heterogeneity, substantial heterogeneity and considerable heterogeneity, respectively. P < 0.05 was considered to indicate statistical significance. A sensitivity analysis was performed to test the robustness and reliability of the pooled results. A funnel plot was used to assess the potential publication bias, with asymmetry indicating publication bias. Egger’s test was used to identify publication bias using Stata 15.0. In addition, the “trim and fill” method was used in detecting and adjusting possible publication bias [28].

Result

Search results

In total, 2431 records were retrieved from 10 databases (6 English and 4 Chinese) and other resources (n = 4). After removing 842 duplicates, 1593 articles were screened by title and abstract. This excluded 1440 records, leaving 153 for full-text review. Among these, 22 were excluded due to lack of full text. A further 115 did not meet eligibility criteria, primarily because they involved wrong population, wrong study design, wrong outcomes, publication type, unable to extract data. Finally, 16 studies were included in the review [23, 29–43].

Fig. 1.

PRISMA flow diagram

Study characteristics

Table 2 summarizes the characteristics of the included studies. All 16 RCTs were published between 2022 and 2024, predominantly conducted in China (n = 13), with one each from the United States, Turkey, and Pakistan. These studies enrolled a total of 1408 patients with CAD, including populations post-percutaneous coronary intervention (n = 2), with acute myocardial infarction (n = 4), after stent implantation (n = 4), with general CAD (n = 4), or post-coronary artery bypass grafting (n = 2). The mean age of participants ranged from 45.7 to 68.0 years. Of the 15 studies reporting sex distribution, all included both male and female participants, with males comprising the majority. One study did not report participant sex or age. Kinesiophobia was assessed using the Tampa Scale for Kinesiophobia in all studies, and several also reported outcomes such as quality of life, psychological resilience, cardiac function, and physical activity. Follow-up was specified in 14 studies, while two reported only post-intervention data.

Table 2.

Characteristics of included studies (N = 16)

Study information			Intervention and Comparison		Participants			Measures		Outcome
Author (year), Country	Type of CAD	Setting	Intervention details	Comparison	Number(E/C)	Age(E/C)	Male/ Female(E/C)	Primary outcome	Secondary outcome	Follow- up
Cognitive-behavioral interventions
Jia XH (2024), China [29]	Stent implantation	university hospital	Type: cognitive-behavioral intervention Frequency: 3 times during hospitalization (the day after surgery, the second day after surgery, and the day of discharge), and once a week for 1 to 4 weeks after discharge. Duration:35–45 min	Usual rehabilitation care	N = 80 (E = 40,C = 40)	E(59.98 ± 10.1) C(60.28 ± 10.12)	E(M = 29,F = 11) C(M = 24,F = 16)	TSK-SV Heart: The Tampa Scale for Kinesiophobia Heart	①Cardiac adverse events	1month、3months
Zhang L (2024), China [30]	Coronary artery bypass grafting	university hospital	Type: cognitive-behavioral intervention Frequency: 3 times during hospitalization Early post-operative period, before discharge, the day of discharge), and once a week for 1 to 4 weeks after discharge. Duration:30 min	Usual nursing care	N = 72 (E = 36,C = 36)	E(59.5 ± 9.2) C(60.5 ± 8.8)	E(M = 23,F = 13) C(M = 25,F = 11)	TSK-SV Heart: The Tampa Scale for Kinesiophobia Heart	①Self-Rating Anxiety Scale/Self-Rating Depression Scale(SAS/ SDS)②Coronary artery disease Self Scale management(CSMS)	1month、3months
Psychological-related interventions
Niu ZX (2024), China [32]	Acute myocardial infarction	Hospital	Type: Psychological care interventions based on the PERMA model. Frequency: Face-to-face intervention was performed twice in the hospital, and intervention was performed once a week for 5 weeks after discharge by means of Internet and telephone. A total of 7 interventions. Duration:20–30 min	Usual nursing care and rehabilitation	N = 160 (E = 80,C = 80)	E(58.13 ± 9.01) C(58.84 ± 10.15)	E(M = 58,F = 22) C(M = 57,F = 23)	TSK-Heart: Tampa Scale for kinesiophobia Heart	①the Connor Davidson Resilience Scale(CD-RISC)	6 weeks
Demirci. C (2023) Turkey [31]	Acute myocardial infarction	in the CICU of a university hospital	Type: Mindfulness practice Frequency: for a total 8 weeks, once a week. Duration:15 min	a single-time attention- matched education	N = 56 (E = 28,C = 28)	E(55.0 ± 10.0) C(55.5 ± 9.6)	E(M = 23,F = 5) C(M = 24,F = 4)	TSK-H: Tampa Scale for Kinesiophobia for Heart	①MacNew Quality of Life Questionnaire (MacNew)	4 weeks、8 weeks、12 weeks
Chen C (2024), China [33]	After percutaneous coronary intervention	Hospital	Type: Pain management based on fear-avoidance model Frequency: Face-to-face intervention was performed 3 in the hospital, once a week for 1 to 4 weeks and twice a week for 5 to 8 weeks after discharge. A total of 9 interventions Duration:30–40 min	Usual care model	N = 72 (E = 36,C = 36)	E(57.53土8.96) C(60.86士10.51)	E(M = 26,F = 10) C(M = 31,F = 5)	TSK-SV Heart: The Tampa Scale for Kinesiophobia Heart	①angina pain	12 weeks
Liu Q (2022), China [24]	Coronary heart disease	Hospital	Type: Graded exposure Frequency: One face-to-face interview and five imaginary exposures combined with on-site exposures were conducted, totaling 6 times. Duration: None	Usual care model	N = 78 (E = 38,C = 40)	E(57.53 ± 7.52) C(57.05 ± 8.46)	E(M = 22,F = 16) C(M = 20,F = 20)	TSK-SV Heart: The Tampa Scale for Kinesiophobia Heart	①the Connor Davidson Resilience Scale(CD-RISC)	3 months
Exercise-related interventions
Li JH (2023), China [40]	After percutaneous coronary intervention	university hospital	Type: Nurse-led high-intensity phase II exercise rehabilitation Frequency: None Duration: None	Routine home-based phase II cardiac rehabilitation	N = 65 (E = 32,C = 33)	E(67.72 ± 4.30) C(66.48 ± 4.37)	E(M = 19,F = 13) C(M = 20,F = 13)	TSK-SV Heart: The Tampa Scale for Kinesiophobia Heart	①Short Form (36) Health Survey(SF-36) ②Peak oxygen uptake (VO2 peak) ③Anaerobic threshold (AT)	12 weeks
Deka.P (2021), The United States [35]	Coronary heart disease	Hospital	Type: The exercise program includs high-intensity, moderate-intensity, and low intensity treadmill walking Frequency: Once a week for 8 weeks in hospital Duration:30 min	Standard medical treatment without any formal exercise participation during the intervention period.	N = 90 (E = 45,C = 45)	Not available	Not available	TSK-11: The Tampa Scale for Kinesiophobiae11	①Hospital Anxiety and Depression Scale(HADS-A/HADS-D) ②the International Physical Activity Questionnaire(IPAQ)	8 weeks
Multi-modal combined nursing interventions
Wang YF (2023), China [36]	Acute myocardial infarction	university hospital	Type: Fear management theory-based psychotherapy combined with exercise rehabilitation. Frequency: None Duration: None	Usual rehabilitation exercise management	N = 80 (E = 40,C = 40)	E(66.45 ± 4.39) C(66.32 ± 4.41)	E(M = 25,F = 15) C(M = 23,F = 17)	TSK-Heart: The Tampa Scale for Kinesiophobia Heart	①Self-Rating Anxiety Scale/Self-Rating Depression Scale(SAS/ SDS) ②left ventricular ejection fraction (LVEF)③ Incidence of adverse cardiac events ④ Exercise adherence	6 months
Lv WQ (2022), China [37]	Coronary heart disease	Hospital	Type: Cognitive behavioral therapy combined with targeted exercise rehabilitation Frequency: None Duration: None	Usual Care	N = 88 (E = 44,C = 44)	E(64.1 ± 2.4) C(63.5 ± 2.1)	E(M = 25,F = 19) C(M = 26,F = 18)	TSK-SV Heart: The Tampa Scale for Kinesiophobia Heart	①Medical Coping Mode Questionnaire(MCMQ)	Not available
Li H (2022), China [38]	Stent implantation	university hospital	Type: Double heart nursing model: cardiac rehabilitation combined with psychological nursing Frequency: None Duration: None	Usual Care	N = 168 (E = 82,C = 86)	E(56.62 ± 5.78) C(59.43 ± 6.87)	E(M = 59,F = 23) C(M = 64,F = 22)	TSK-SV Heart: The Tampa Scale for Kinesiophobia Heart	①Self-Rating Anxiety Scale(SAS)②Short Form (36) Health Survey(SF-36)③Newcastle Satisfaction with Nursing Scales(NSNS)	Not available
Chang GJ (2023), China [39]	Acute myocardial infarction	Hospital	Type: Double heart nursing model: cardiac rehabilitation combined with psychological nursing Frequency: None Duration:10–30 min	Usual Care	N = 98 (E = 49,C = 49)	E(45.72 ± 4.45) C(46.25 ± 4.30)	E(M = 28,F = 21) C(M = 29,F = 20)	TSK-SV Heart: The Tampa Scale for Kinesiophobia Heart	①Somatization subscale of the Symptom Checklist-90(SCL-90)②Compliance behavior ③Newcastle Satisfaction with Nursing Scales(NSNS)	1 month
Wang DD (2024), China [42]	Stent implantation	Hospital	Type: Double heart nursing model: cardiac rehabilitation combined with psychological nursing Frequency: None Duration: None	Usual Care	N = 88 (E = 44,C = 44)	E(65.34 ± 6.85) C(65.19 ± 6.74)	E(M = 27,F = 17) C(M = 24,F = 20)	TSK-Heart: Tampa Scale for kinesiophobia Heart	①General Self-Efficacy Scale (GSES)②Short Form (36) Health Survey(SF-36)	1 month
Liu JL (2024), China [41]	Stent implantation	Hospital	Type: Traditional Chinese Medicine based psychotherapy combined with aerobic exercise training Frequency: Exercise training three times a week for one month. Duration: Exercise training: 30–60 min	Usual rehabilitation interventions	N = 72 (E = 36,C = 36)	E(64.83 ± 7.23) C(64.47 ± 7.39)	E(M = 19,F = 17) C(M = 21,F = 15)	TSK-SV Heart: The Tampa Scale for Kinesiophobia Heart	①Left ventricular ejection fraction (LVEF) ②Peak oxygen uptake (VO2 peak) ③Anaerobic threshold (AT) ④6-minute walking distance (6MWD) ⑤Short Form-8 Health Survey(SF-8)	1 month
Interventions not clearly categorized
Kiran Khushnood (202), Pakistan [23]	Coronary Artery Bypass Grafting	ICU of hospital	Type: Inspiratory muscle training (IMT) with breathing exercises and chest clearance techniques Frequency: Three treatment sessions before scheduled surgery Duration:30–40 min	Only breathing exercises and chest clearance techniques	N = 50 (E = 25,C = 25)	E(53.96 ± 5.74) C(52.24 ± 5.50)	E(M = 17,F = 8) C(M = 17,F = 8)	TSKH: Tampa scale of kinesiophobia for heart	①6MWT ②Pulse rate ③Respiratory rate ④Borg RPE ⑤Oxygen saturation ⑥ICU stay	Not available
Chen Y (2024), China [43]	Coronary heart disease	university hospital	Type: Online and offline home rehabilitation programs based on BCW theory Frequency: None Duration: None	Usual Care	N = 91 (E = 45,C = 46)	E(68.0 ± 4.0) C(66.0 ± 4.2)	E(M = 26,F = 19) C(M = 26,F = 20)	TSK-Heart: Tampa Scale for kinesiophobia Heart	①Left ventricular ejection fraction (LVEF) ②Peak oxygen uptake (VO2 peak) ③Anaerobic threshold (AT) ④6-minute walking distance (6MWD) ⑤Chinese version Patient Activation Measure 13 (PAM13) score	3 month 6 months

Types of interventions

Interventions were categorized by study’s objectives and primary components as follows: cognitive-behavioral therapy (2 studies [29, 30]), psychological interventions (4 studies, including PERMA-based care [32], mindfulness [31], fear-avoidance [33], and graded exposure [34]), exercise-based programs (high-intensity intermittent exercise; 2 studies [35, 40]), and multimodal interventions (6 studies, incorporating cognitive-rehabilitation exercise [36, 37], dual-heart nursing [38, 39, 42], and Traditional Chinese Medicine psycho-exercise approaches [41]). Additionally, one study delivered online-offline home rehabilitation [43], and another evaluated preoperative physical therapy [23].

Risk of bias in the studies included

The risk of bias was independently assessed by two researchers. Overall quality is summarized in Fig. 2. Several studies mentioned randomization but did not describe the method, resulting in a high risk of selection bias. Allocation concealment and blinding were often insufficiently detailed. Attrition and reporting bias were generally low across studies. However, in some studies, the lack of precise timing for outcome assessment may have influenced the reliability of intervention effects, contributing to other potential biases.

Fig. 2.

Risk of bias graph and summary (n = 16)

Effectiveness of interventions

Of the 17 studies included in the meta-analysis, 13 provided total kinesiophobia scores. Due to substantial heterogeneity (I² = 94%, P < 0.01), a subgroup analysis by intervention type was conducted. As summarized in Fig. 3, all intervention categories significantly reduced kinesiophobia (P < 0.01), with effect sizes (SMD, 95% CI) as follows: cognitive–behavioral (n = 2): − 2.75 (–3.81, − 1.96); psychological (n = 4): − 1.70 (–2.08, − 1.32); exercise (n = 2): − 1.24 (–1.59, − 0.90); multimodal (n = 3): − 3.88 (–4.70, − 3.05). Single studies of online/offline home rehabilitation and preoperative physical therapy also showed significant effects.

Fig. 3.

Forest plot of interventions on total kinesiophobia scores (n = 13)

Effectiveness of different follow-up times

Only ten studies reported detailed time of follow-up, we performed subgroup analysis at different times, respectively. It comes out that at 1–2 months (1 month; 6 weeks; 2 months) (P < 0.01; SMD=-1.75; 95% CI=-2.16, -1.34), 3 months (P < 0.01; SMD=-2.04; 95%CI=-2.66, -1.42), and 6 months (P < 0.01; SMD = -4.90; 95%CI = -7.59, -2.20) all have significant effects (Fig. 4). However, there was no difference in kinesiophobia scores between 1 and 3 months after the intervention (Additional file 1).

Fig. 4.

Forest plot of kinesiophobia scores at different follow-up times for interventions (n = 10)

Effectiveness on psychological status, cardiac function, quality of life, and exercise ability in CAD patients with kinesiophobia

Effectiveness on psychological status

Seven studies assessed psychological outcomes. Pooled results from two studies using the CD-RISC scale showed a significant improvement in psychological resilience (MD = 7.83; 95%CI: 6.07, 9.59; P < 0.01; I² = 0%, fixed-effects model). Data from four studies on anxiety levels (assessed by SAS or HADS-A) demonstrated a significant reduction in anxiety (SMD = -1.35; 95%CI: -2.19, -0.52; P < 0.01; I² = 93%, random-effects model) (Fig. 5).

Fig. 5.

Forest plot of psychological status (n = 6). Note: (a): anxiety (b): Psychological Resilience

Effectiveness on cardiac function

A fixed-effects meta-analysis of three studies for each cardiac parameter showed that the interventions significantly improved left ventricular ejection fraction (MD = 3.42%; 95% CI: 2.15, 4.70), peak oxygen uptake (MD = 2.47; 95% CI: 1.88, 3.06), and anaerobic threshold oxygen uptake (MD = 2.05; 95% CI: 1.65, 2.45) (all P < 0.01; I² = 0%) (Fig. 6).

Fig. 6.

Forest plot of cardiac function (n = 4). Note: (c): LVEF (d): VO2Peak (e): ATVO2

Effectiveness on quality of Life

Analysis of three studies reporting complete data from the MacNew or SF-36 questionnaires indicated a statistically significant improvement in quality of life (SMD = 0.87; 95% CI: 0.42, 1.32; P < 0.01) (Fig. 7).

Fig. 7.

Forest plot of quality of Life (n=3) Note: (f): MacNew, SF-36

Effectiveness on exercise ability

Meta-analysis of four studies using IPAQ, 6MWD, or the Exercise Adherence Scale revealed a significant positive effect on exercise ability (SMD = 1.70; 95% CI: 0.67, 2.72; P < 0.01) (Fig. 8).

Fig. 8.

Forest plot of exercise ability (n = 4) Note: (g): IPAQ, 6MWD, Exercise Adherence Scale

Publication bias and sensitivity analysis

This meta-analysis used funnel plot and Egger liner regression to evaluated the publication bias. The funnel plot revealed some asymmetry with the Egger’s test confirmed significant publication bias on kinesiophobia (t = -2.69, P< 0.05). A trim and fill method is performed further and imputed potentially one study to yield an adjusted effect size with a larger effect size than the overall effect size of -2.57 measured in 13 studies (14 studies, SMD = -2.71, 95% CI=-3.39, -2.02). This result showed that the overall effect was extremely stable (Fig. 9).

Fig. 9.

Publication bias

Moreover, sensitivity analysis of one-by-one elimination showed a stable effect size between the interventions and kinesiophobia. Therefore, it was suggested that the results drawn from the meta-analysis were reliable(Additional file 1).

Discussion

This systematic review and meta-analysis synthesized evidence from 16 randomized controlled trials to evaluate the effectiveness of interventions targeting kinesiophobia in patients with coronary artery disease (CAD). Overall, a range of intervention strategies—including cognitive–behavioral therapy (CBT), psychological-based interventions, exercise-related rehabilitation, multimodal programs, and home-based rehabilitation delivered through both online and offline formats—were associated with significant reductions in kinesiophobia compared with usual care. These effects were observed across short- and mid-term follow-up periods, supporting the view that kinesiophobia represents a modifiable psychological–behavioral factor within cardiac rehabilitation. However, interpretation of these findings requires consideration of the methodological variability and heterogeneity among the included studies.

Among intervention types, CBT and multimodal interventions demonstrated relatively greater effects. Kinesiophobia in CAD is often driven by maladaptive threat appraisal of exertion-induced cardiac risk and heightened attention to bodily sensations [16, 44]. CBT addresses these mechanisms by modifying dysfunctional beliefs and promoting graded behavioral exposure, thereby reducing avoidance behaviors and improving perceived control and exercise self-efficacy [45, 46]. Multimodal interventions may provide additional benefits by simultaneously targeting cognitive, emotional, and physiological pathways. Supervised exercise offers safe exposure to exertion-related sensations, helping patients disconfirm maladaptive beliefs while improving physical conditioning [47, 48]. Moreover, multimodal interventions are frequently integrated into routine cardiac rehabilitation programs, which may enhance clinical feasibility and support treatment adherence as well as long-term behavioral maintenance [5, 49]. Nevertheless, substantial heterogeneity in intervention composition, intensity, and delivery formats limits definitive conclusions regarding optimal treatment configurations and current findings should be interpreted as indicative of the potential advantage of multicomponent approaches rather than evidence supporting any combinations of intervention components.

Exercise-related interventions alone also significantly reduced kinesiophobia, suggesting that exercise may exert psychological benefits beyond its established physiological effects. Repeated supervised activity may help recalibrate threat perceptions and restore confidence in physical capability [50, 51]. Consistent with the fear-avoidance model, regular physical activity may disrupt cycles of avoidance and functional decline by fostering engagement, functional recovery, and self-efficacy [52]. However, intervention effectiveness may vary across patient subgroups [7], highlighting the need for individualized exercise prescriptions considering modality (e.g., aerobic vs. resistance; individual vs. group-based), intensity, frequency, and supervision level.

Beyond primary outcomes, interventions also improved secondary outcomes, including psychological resilience, anxiety, cardiac function, quality of life, and exercise capacity. These findings suggest that kinesiophobia influences broader psychological and functional recovery in CAD, consistent with previous evidence [53, 54]. Reduction of kinesiophobia may exert beneficial effects through integrated psychological–behavioral–physiological pathways. Specifically, alleviating fear of movement may enhance exercise adherence by improving risk perception and self-efficacy, thereby promoting cardiopulmonary function [21, 55]. Exercise participation may further regulate autonomic function, inflammatory responses, and neuroendocrine balance, contributing to reduced anxiety and enhanced resilience [56, 57]. Nevertheless, different intervention modalities may exert distinct effects on secondary outcomes. Cognitive-behavioral interventions appear more effective for psychological endpoints, whereas exercise training and comprehensive cardiac rehabilitation more directly improve functional parameters. Considerable heterogeneity in intervention type, intensity, and duration among included studies currently limits the identification of optimal strategies.

Interventions significantly reduced kinesiophobia at 1, 3, and 6 months. The absence of additional improvement between 1 and 3 months suggests stage-dependent intervention effects. According to the transtheoretical model of behavior change [58], the early improvements observed after intervention may be related to the fact that patients in the acute post-event phase are generally more receptive to health behavior guidance, and interventions may facilitate progression from the preparation stage to the action stage. This finding indicates that the early phase of CR may represent a critical time window for implementing psychological and behavioral interventions. However, the lack of significant additional improvement between 1 and 3 months suggests that kinesiophobia may function as a relatively stable psychological construct in the short term. Longitudinal evidence from Keessen et al. [59]. supports this interpretation, showing that kinesiophobia follows a relatively stable trajectory during the first 12 weeks after cardiac hospitalization and does not exhibit cross-lagged associations with objectively measured physical activity. Taken together with the our findings, it can be inferred that early interventions may primarily influence patients’ risk perception and psychological responses, whereas further reductions in kinesiophobia may require longer-term or more individualized intervention strategies. In addition, the increased effect observed at 6 months suggests potential cumulative benefits of certain interventions. For example, exercise training and CBT may promote long-term psychological adaptation by continuously reinforcing positive movement experiences and perceptions of safety. However, the relatively limited follow-up durations among included studies prevent firm conclusions regarding long-term effectiveness, highlighting the need for extended longitudinal investigations.

With advances in digital health technologies, tele-cardiac rehabilitation has emerged as an important adjunct to conventional programs. Current evidence regarding its long-term superiority in reducing kinesiophobia remains limited, with some studies showing comparable effects to center-based rehabilitation [60, 61]. This may be because traditional programs may enhance fear reduction through close monitoring, professional supervision, and face-to-face interaction that improve patients’ sense of safety and control. Tele-rehabilitation offers greater accessibility and flexibility, potentially improving adherence but reducing real-time supervision [62]. Emerging evidence also suggests that hybrid models combining tele- and center-based rehabilitation may optimize accessibility while maintaining psychological support, thereby improving kinesiophobia outcomes.

Methodological quality among included studies varied. Several trials reported randomization without detailed descriptions of allocation procedures, and allocation concealment and blinding were frequently insufficiently reported, potentially introducing selection and performance bias. Additionally, variability in outcome assessment timing may have influenced reliability of intervention effects. Publication bias was detected; however, trim-and-fill analysis suggested that the pooled effect size remained stable. Sensitivity analyses further confirmed the robustness of the findings. Nevertheless, heterogeneity in intervention design, duration, and outcome measurement tools remains a major limitation that may affect result generalizability.

Strength and limitations

This systematic review and meta-analysis presents several key strengths. To our knowledge, it is the first to synthesize randomized controlled trial evidence on interventions specifically designed to reduce kinesiophobia in patients with coronary artery disease. By systematically categorizing intervention types—including cognitive-behavioral therapy, psychological approaches, exercise-based programs, multimodal rehabilitation, and tele-rehabilitation—the review offers a comprehensive overview of current therapeutic strategies. Temporal subgroup analyses across clinically relevant follow-up periods were also conducted, allowing for the examination of stage-dependent intervention effects and providing novel insights into the trajectory of kinesiophobia reduction. Furthermore, by evaluating multidimensional outcomes such as psychological status, cardiac function, exercise capacity, and quality of life, this review underscores the broader clinical relevance of addressing kinesiophobia within cardiac rehabilitation.

However, several limitations should be acknowledged. First, the exclusive inclusion of RCTs, while maximizing internal validity for causal inference, may have excluded relevant evidence from high-quality observational studies or other intervention designs, potentially limiting the breadth and generalizability of our findings. Considerable heterogeneity in intervention protocols, outcome measures, and follow-up durations may limit direct comparison across studies. Methodological shortcomings, including insufficient reporting of allocation concealment and blinding, may introduce potential bias. Additionally, relatively short follow-up periods restrict evaluation of long-term intervention sustainability. Publication bias was detected, although sensitivity analyses suggested stable pooled estimates. Finally, variability in patient characteristics across studies may limit generalizability of findings.

Clinical implications

The findings highlight the importance of integrating kinesiophobia-targeted interventions into routine cardiac rehabilitation. Early identification and management of kinesiophobia should be considered essential components of secondary prevention in CAD. Combining psychological therapies, particularly cognitive–behavioral approaches, with supervised exercise programs may effectively address maladaptive risk perceptions while simultaneously reducing kinesiophobia. Hybrid rehabilitation models that integrate center-based and tele-rehabilitation approaches may further enhance accessibility and adherence while maintaining patient safety and psychological support. Multicomponent interventions should be individualized according to patient characteristics, rehabilitation needs, and delivery preferences. Given the relative short-term stability of kinesiophobia, sustained reduction may require ongoing, personalized intervention strategies and flexible delivery formats. Interdisciplinary collaboration between cardiology, rehabilitation, and behavioral health specialists may further enhance intervention effectiveness and clinical implementation.

Future research directions

Future studies should aim to establish standardized intervention protocols to reduce heterogeneity and facilitate comparison across therapeutic approaches. Large-scale, multicenter randomized trials with rigorous methodological design are needed to strengthen evidence quality. Research should also explore patient-level moderators to support individualized rehabilitation strategies. Moreover, long-term follow-up studies are required to determine sustainability of intervention effects and identify optimal treatment duration. Further investigation into tele-rehabilitation and hybrid delivery models, incorporating objective monitoring technologies, may improve adherence and long-term behavioral outcomes.

Conclusion

This systematic review and meta-analysis demonstrates that interventions targeting kinesiophobia are effective in patients with coronary artery disease. Cognitive–behavioral therapy, psychological interventions, exercise-based rehabilitation, and multimodal rehabilitation strategies were all associated with significant reductions in kinesiophobia, with cognitive–behavioral therapy and multimodal rehabilitation programs demonstrating comparatively greater effectiveness. Intervention benefits were observed across short- and mid-term follow-up periods, with early improvements emerging within the first month and potential cumulative benefits appearing at later stages. These findings suggest that kinesiophobia represents a modifiable psychological–behavioral barrier that should be addressed as a core component of cardiac rehabilitation. Early implementation of targeted interventions may effectively modify catastrophic beliefs and reduce kinesiophobia, whereas further reductions may require individualized intervention strategies tailored to patient-specific needs. Hybrid rehabilitation models integrating tele-rehabilitation with center-based programs may further enhance accessibility and long-term participation. However, heterogeneity in intervention protocols, methodological limitations, and relatively short follow-up durations among existing studies restrict definitive conclusions regarding optimal intervention configurations and long-term sustainability. Future high-quality, multicenter randomized trials with standardized intervention frameworks and extended follow-up are required to clarify long-term effectiveness and support individualized rehabilitation strategies.

Authors’ contributions

Lingqiao Gong: Conceptualization, Data curation, Formal analysis, Methodology, Software, Writing. Panpan Xu: Conceptualization, Data curation, Formal analysis, Methodology, Software. Xue Chen: Conceptualization, Supervision, Validation, Writing. Yue Kuang: Conceptualization, Data curation, Methodology, Validation. Hong Tang: Conceptualization, Data curation, Software, Validation, Supervision. All listed authors (Lingqiao Gong, Panpan Xu, Yue Kuang, Hong Tang and Xue Chen) meet the criteria for authorship, and all authors agree with the content of the manuscript.

Funding

This project was supported by grants from the Department of Health of Jilin Province (2024A042) and the Department of Education of Jilin Province (JJKH20250224KJ) to corresponding author Xue Chen.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

Not Applicable.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.