Dyadic Coping with Dyspnoea-Related Kinesiophobia in Couples Living with COPD: “Entrapped Together or Moving Through Together” – A Constructivist Grounded Theory

Abstract

Aim

To generate a theory explaining how patients with chronic obstructive pulmonary disease (COPD) and their partners experience and navigate the process of coping with dyspnoea-related kinesiophobia within everyday pulmonary rehabilitation and home-based disease management.

Methods

A qualitative study using constructivist grounded theory was conducted in the respiratory department of one large tertiary hospital and its affiliated community health service centre in Shanxi Province, China. Initial purposive sampling and subsequent theoretical sampling were used to recruit 21 couples, comprising clinically stable patients with COPD and kinesiophobia (operationally defined as Breathlessness Beliefs Questionnaire–Activity Avoidance subscale score >6) and their cohabiting partners. Data were collected through face-to-face dyadic interviews. Concurrent data analysis employed a constant comparative approach, facilitated by NVivo 12 software, to iteratively refine emerging codes and categories.

Results

The 21 patients represented GOLD airflow limitation grades 1–3, including grade 1 (n=2), grade 2 (n=12), and grade 3 (n=7). Analysis generated the core category “Entrapped Together or Moving Through Together”, which conceptualises kinesiophobia as a dynamic dyadic process rather than solely an individual experience. Patients’ symptom-related fear entered couple interactions through two distinct patterns: patients’ expressions of distress elicited kinesiophobia and protective anxiety in partners, whereas partners’ protective monitoring and restriction could become incorporated into patients’ movement-related concerns. Couples subsequently responded through four patterns—joint avoidance, motivational conflict, support mismatch, and the paradox of love. Over time, these interactions were associated with two contrasting relational states: becoming “entrapped together” through persistent avoidance and overprotection, or “moving through together” through communication, role adjustment, and accumulated successful experiences. These relational states could, in turn, shape subsequent couple interactions around kinesiophobia.

Conclusion

The findings reveal profound dyadic interdependence in coping with kinesiophobia, providing support for the development of rehabilitative frameworks prioritising both objective functional outcomes and the subjective experiences of both partners. A couple-centred model of support warrants development and evaluation for sustainably improving rehabilitation trajectories for both patients and their partners.

Introduction

Chronic obstructive pulmonary disease (COPD), the third leading cause of death globally, is a chronic respiratory disease characterised by high prevalence, progressive functional decline, and substantial socioeconomic burden.^1–3 Pulmonary rehabilitation is an important component of the comprehensive management of COPD.⁴ The European Respiratory Society (ERS) and American Thoracic Society (ATS) define pulmonary rehabilitation as a comprehensive, individualised intervention incorporating exercise training, education, and behaviour change, with the aim of improving patients’ physical and psychological condition and promoting long-term adherence to health-enhancing behaviours.^5,6 Exercise training is the cornerstone of pulmonary rehabilitation and is effective in improving exercise capacity, health-related quality of life, and other clinically relevant outcomes in patients with COPD.^7–9 However, despite the well-established benefits of pulmonary rehabilitation, sustained engagement in exercise remains disappointingly low. Previous studies have reported that only 8.3%–49.6% of patients with COPD regularly participate in exercise programmes,¹⁰ while more than one-third discontinue pulmonary rehabilitation prematurely.¹¹ This substantial evidence–practice gap suggests that important barriers to long-term rehabilitation participation remain insufficiently understood. Reduced exercise participation in patients with COPD may reflect both physiological and psychological factors. From a physiological perspective, expiratory flow limitation can impair lung emptying, particularly when the increased ventilatory demand and respiratory rate during physical activity shorten expiratory time. This may result in progressive air trapping and dynamic hyperinflation, with a corresponding reduction in inspiratory capacity. As lung volumes increase, the capacity for further tidal volume expansion becomes increasingly constrained, while inspiratory neural drive continues to rise, creating a mismatch between respiratory drive and the mechanical response of the respiratory system. These abnormalities contribute substantially to exertional dyspnoea and exercise intolerance in COPD. Consequently, particularly in patients with more pronounced ventilatory limitations, reducing or modifying physical activity may partly reflect genuine physiological constraints. In contrast, maladaptive fear-driven activity avoidance may occur when the anticipation of breathlessness and concerns that physical activity will provoke or aggravate symptoms lead patients to restrict or avoid activity.¹²

Increasing evidence indicates that kinesiophobia has emerged as one of the most important psychological barriers limiting exercise participation among people with COPD.^13,14 A cross-sectional study of older adults with COPD in China reported that the prevalence of dyspnoea-related kinesiophobia was 88.9%.¹⁵ Higher levels of kinesiophobia have been associated with lower physical activity participation, poorer pulmonary rehabilitation adherence, reduced functional capacity, and impaired quality of life.^16,17 Dyspnoea-related kinesiophobia, defined as the persistent fear and activity-avoidance behaviours arising from concerns that physical activity may provoke or aggravate intolerable breathlessness, has been recognised as the most disease-specific subtype of kinesiophobia and a fundamental psychological obstacle to pulmonary rehabilitation.¹⁸ Consequently, dyspnoea-related kinesiophobia has emerged as a critical psychological concern warranting urgent attention in the long-term exercise management and pulmonary rehabilitation of COPD patients. Of note, such fear-avoidance behaviours do not exist in isolation at the individual patient level; rather, their formation, maintenance, and modification are embedded within patients’ most intimate family interaction contexts.¹⁹

As a progressive long-term condition, COPD management and rehabilitation are largely delivered within the home environment.^20,21 Within the caregiving system of COPD patients, partners typically assume the primary supportive role.²² These informal caregivers commonly face multiple stressors: upon assuming caregiving responsibilities, often unexpectedly, their psychological resilience may be significantly compromised.^20,23 Beyond directly managing fluctuations in patients’ clinical status, partners must also contend with a fundamental tension between “encouraging activity” and “restricting activity”—a tension that generates profound psychological dissonance. This role conflict may crystallise into enduring intrapersonal strain; together, these forces often culminate in a state of emotional exhaustion and helplessness.²⁴ Upon discharge and return to the home setting, these challenges are frequently exacerbated by the withdrawal of professional support that had been available within institutional care.²⁰ Notably, while fulfilling their caregiving functions, partners concurrently bear the persistent psychological burden of hypervigilance regarding patients’ potential acute deteriorations.²³ In navigating the delicate balance between ensuring patient safety and promoting functional recovery, this dual burden intensifies spousal emotional depletion and underscores the cyclical relationship between caregiver well-being and patient recovery trajectories.

The experiences of patients with COPD and their partners reveal an interdependent trajectory: while patients contend with the functional limitations and activity avoidance associated with dyspnoea and kinesiophobia, partners bear parallel yet distinct psychosocial burdens, collectively shaping a disease-coping process that extends beyond the individual level. This interdependence calls for a dyadic perspective on kinesiophobia in COPD that considers how patients’ and partners’ experiences and responses become interconnected within their everyday interactions. Existing dyadic coping models provide an important theoretical perspective for understanding such interdependence in the context of chronic illness. These models generally conceptualise illness-related stress as a shared challenge and emphasise that partners’ appraisals, communication, and coping responses are interrelated throughout the process of adaptation. Thus, dyadic coping extends beyond the sum of two individuals’ coping responses and represents a relational process embedded within couple interactions.^25,26

Despite this broader recognition of the relational nature of coping, research on kinesiophobia in COPD has predominantly focused on patients’ individual characteristics and determinants, with limited attention to partners’ experiences and couple-level interactions.^18,27,28 Consequently, little is known about how patients and partners experience, negotiate, and respond to dyspnoea-related kinesiophobia within their everyday interactions, or how their respective responses become interconnected over time. Addressing this gap may provide a more nuanced understanding of dyspnoea-related kinesiophobia and inform the future development of couple-centred approaches to support both patients and their partners. Therefore, the present study aimed to explore the shared experiences and coping processes of patients with COPD and their partners in relation to dyspnoea-related kinesiophobia and to construct a theoretical framework explaining their interconnected coping processes. The core research question was: “How do patients with COPD and their partners jointly experience and cope with the dyadic interactive process of dyspnoea-related kinesiophobia?”

Materials and Methods

Design

This study employed Charmaz’s constructivist grounded theory approach,²⁹ and it is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist.³⁰ Constructivist grounded theory is underpinned by a relativist ontology and a constructivist epistemology, emphasising the co-construction of multiple, subjective realities.²⁹ This methodology was considered particularly appropriate because the present study sought not only to explore the lived experiences of breathlessness-related kinesiophobia among patients with COPD and their partners, but also to develop an explanatory theoretical framework describing how dyadic respond to and cope with dyspnoea-related kinesiophobia within dyadic interaction.

Setting

Participant recruitment and interview data collection were conducted from January to February 2026 in the respiratory department of a tertiary hospital and its affiliated community health service centre in Shanxi Province, China. The tertiary hospital provides diagnosis, treatment, and pulmonary rehabilitation for patients with chronic respiratory diseases, whereas the affiliated community health service centre delivers long-term follow-up management and rehabilitation guidance after hospital discharge. This integrated hospital–community healthcare system enabled the recruitment of patients with COPD and their partners across different stages of disease management, thereby facilitating exploration of their shared experiences, interactions, and dyadic coping processes in the context of dyspnoea-related kinesiophobia in the context of breathlessness-related kinesiophobia.

Sampling and Sample Size

A purposive sampling approach was initially employed to recruit couples, with the couple considered as the analytical unit,³¹ who met the inclusion criteria. As the study progressed, a theoretical sampling approach was used to recruit additional couples who could contribute to the development of the emerging theory until data saturation was achieved.³² For instance, following the identification of the “paradox of love” as overprotection among some partners, couples with this characteristic were purposively recruited to explore this contradictory interaction pattern in greater depth. Theoretical saturation was considered to have been reached when additional interviews no longer generated new categories, properties of existing categories, or substantive relationships among categories. When ongoing analysis indicated that theoretical saturation had been reached, two additional couples were recruited to assess and confirm saturation. Analysis of these additional interviews yielded no new categories, properties, or substantive theoretical relationships, supporting the determination of theoretical saturation.

Participants and Recruitment

Based on the study objectives, the inclusion criteria for patients were as follows: (1) Participants were required to have a confirmed diagnosis of COPD according to the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) diagnostic criteria.⁴ For both hospital and community participants, eligibility was determined from existing medical records, which documented post-bronchodilator spirometry showing FEV₁/FVC <0.70, (2) The present study used the Activity Avoidance subscale of the Breathlessness Beliefs Questionnaire (BBQ-AA) as an operational definition for participant identification.³³ The BBQ-AA consists of six items scored on a five-point Likert scale (total score range: 6–30), with 6 representing the theoretical minimum score. Because the aim of this constructivist grounded theory study was to recruit participants with experiences relevant to the phenomenon under investigation rather than to distinguish different levels of dyspnoea-related kinesiophobia, and because no validated clinical cut-off for the BBQ-AA is currently available, a score >6 was pragmatically adopted as the operational criterion for participant inclusion. This criterion was intended solely for participant recruitment and should not be interpreted as a clinical diagnostic threshold. Importantly, the BBQ-AA assesses breathlessness-related activity-avoidance beliefs rather than actual physical activity behaviour. (3) Ability to communicate normally, and (4) clinically stable at the time of the interview, defined as having no ongoing acute clinical deterioration requiring immediate escalation of treatment and being considered medically stable by the treating clinical team to complete the interview. The inclusion criteria for partners were as follows: (1) cohabitation with the patient, (2) involvement in the patient’s disease management, (3) willingness to participate, and (4) legal spouse or long-term cohabiting partner for ≥1 year. The exclusion criteria for patients were as follows: (1) presence of severe physical comorbidities that could independently and substantially affect exertional tolerance, mobility, or movement-related fear, including severe cardiovascular disease, severe musculoskeletal disorders, severe hepatic or renal disease, malignancy, other severe respiratory diseases, or other conditions resulting in substantial mobility impairment, or the presence of a terminal illness; and (2) presence of cognitive or mental disorders that prevented effective participation in the interview, or current participation in other intervention studies. The exclusion criteria for partners were as follows: (1) presence of severe physical illness or terminal illness that prevented effective participation in the study; and (2) presence of cognitive or mental disorders that prevented effective participation in the interview, or current participation in other intervention studies.

Recruitment proceeded in three stages. First, respiratory physicians and community general practitioners screened outpatient records and follow-up files to identify potentially eligible patients with COPD based on the inclusion and exclusion criteria. Second, clinical or community nurses approached these initially screened patients, briefly introduced the study aims, and, with their agreement, referred them to a research assistant (RA). Finally, the RA met with the interested patients and their partners at a mutually convenient time and location to provide detailed information about the study procedures, confidentiality, and the voluntary nature of participation; answer any questions; and confirm eligibility. Formal invitation to participate and interview scheduling followed, with the RA ensuring privacy and that participation did not interfere with routine clinical care or daily life. Three couples declined participation due to lack of interest in the study.

Data Collection

Data were collected primarily through semi-structured dyadic interviews and field notes. An interview guide was developed based on the existing literature, the fear-avoidance model,³⁴ and the researchers’ clinical experience (Figure 1). The guide was pilot tested with three couples and subsequently refined. All interviews were conducted face-to-face in quiet, private settings. The interview location varied according to the participant’s situation: Hospitalized patients were interviewed in their physician’s office, while home-based patients were interviewed at a community health service center or their home. Each interview commenced with a 5–10-minute informal conversation to build rapport and allow the interviewer to assess communication styles and potential power dynamics.

Figure 1.

Interview guide. The guide includes parallel questions for patients and their partners.

All interviews were conducted and audio-recorded by the same researcher. All interviews were conducted by the first author, a female doctoral nursing student with formal training in qualitative research methods and experience in conducting COPD-related research. The interviewer had no prior therapeutic or professional relationship with the participants. The researcher began the interviews with a broad, open-ended question about the patient’s experiences with physical activity, encouraging the patient to respond first, followed by their partner. To ensure balanced participation, a respiratory nurse with training in qualitative methods acted as a moderator, ensuring both voices were heard. During the interviews, participants’ facial expressions and body language were simultaneously observed and recorded. Concurrent analysis during the initial round of interviews informed the need for follow-up interviews with some participants to clarify ambiguous statements. All interviews were conducted in Mandarin Chinese and transcribed verbatim in Mandarin Chinese. The original Mandarin Chinese transcripts were used throughout the coding and analytic process. In March 2026, following completion of interview data collection, the complete transcripts were translated from Mandarin Chinese into English by the second and third authors, both of whom were proficient in Mandarin Chinese and English [and familiar with qualitative research and COPD-related clinical terminology]. The first and fourth authors, who were also proficient in both Mandarin Chinese and English, subsequently checked the English translations against the original Mandarin Chinese transcripts to ensure semantic consistency and conceptual equivalence. Any discrepancies were discussed and resolved with reference to the original Mandarin Chinese transcripts and interview context. No formal back-translation was undertaken.

Ethical Considerations

Ethical approval for this study was granted by the Institutional Review Board of the First Hospital of Shanxi Medical University (Approval No. KYLL-2026-033), and the study was conducted in accordance with the principles outlined in the Declaration of Helsinki. All participating patients and their partners provided written informed consent and were assured of their right to withdraw from the study at any time without penalty. The informed consent process also included explicit permission for the publication of anonymized interview data and direct quotations. To ensure confidentiality and data security, all interview records and personal data were rigorously de-identified and anonymised. All quotations presented in the findings are attributed using generic identifiers to protect participant anonymity and minimise the risk of indirect identification.

Researcher Reflexivity

Before data collection, the researcher acknowledged that previous engagement in COPD-related research and familiarity with the literature could shape pre-understandings of kinesiophobia. Given that the interview guide was informed by the fear-avoidance model, the researcher also remained reflexively aware that this theoretical perspective could influence the issues attended to during interviews and the interpretation of participants’ accounts. The fear-avoidance model was used to inform the development of the interview guide rather than as a predetermined framework for coding or category development. To minimize this influence, interviews were guided by open-ended questions, and follow-up questions were developed from participants’ responses rather than the researcher’s expectations. After each interview, the researcher maintained a reflective journal to document personal reflections, assumptions, emotional responses, and potential influences on data collection and interpretation. During data analysis, interpretations were continually compared with the original transcripts, and emerging codes, categories, and interpretations were regularly reviewed and discussed within the research team. Through these discussions, the team critically examined whether emerging interpretations were supported by participants’ accounts or reflected assumptions derived from prior research experience or the fear-avoidance model.

Methodological Rigour/Trustworthiness

The trustworthiness of this study was established using Lincoln and Guba’s framework,³⁵ which emphasises credibility, transferability, dependability, and confirmability. Credibility was enhanced by piloting the interview guide, recruiting only participants who met the established criteria, and conducting repeat interviews where clarification or further exploration was required. Triangulation of data sources through interviews and field notes further enhanced credibility. Transferability was supported by providing detailed descriptions of the participant selection criteria and the study context, enabling readers to assess the applicability of the findings to similar populations and settings. Dependability was ensured by maintaining a comprehensive audit trail documenting all key decisions throughout the research process, as well as a reflexive diary throughout data collection and analysis. All researchers remained mindful not to impose optimistic frameworks that might minimise the traumatic experiences described by the participants. Confirmability was enhanced through member checking. In March 2026, following completion of the preliminary data analysis, participants were contacted and invited to review summaries of the preliminary findings and core interpretive statements in Mandarin Chinese to assess whether the interpretations were consistent with their experiences and perspectives. For selected core expressions that had been translated into English, participants were not asked to evaluate the linguistic quality of the English wording; rather, the meanings conveyed by these expressions were explained and discussed with them in Mandarin Chinese to verify consistency with their original accounts.

Data Analysis

Data analysis employed the constant comparison approach.²⁹ Data analysis proceeded concurrently with data collection from January to February 2026. Verbatim transcription, initial coding, and constant comparison were undertaken iteratively, with emerging categories informing subsequent interviews and theoretical sampling. Two researchers (Liu and Fan) independently reviewed the audio recordings and their corresponding transcripts to ensure accuracy and completeness. Following confirmation of the final versions, coding was undertaken using NVivo 12 software 32.³⁶ During open coding, the two researchers inductively performed line-by-line coding to identify phrases reflecting experiences related to coping with kinesiophobia. Because dyads were used, the open coding phase paid attention to both content (emerging narratives) and interactions. In the focused coding stage, the preceding codes were further examined to ascertain the connections and relationships between them to formulate categories. Any coding disagreements between the two researchers were resolved through discussion within the research team and re-examination of the original transcripts until consensus was reached. Theoretical coding was used to elucidate the relationships between the core category and its sub-categories. Through systematic synthesis of the emerging categories, an inclusive core concept representing the process of coping with kinesiophobia for both the patients and their partners was ultimately formulated. All interview transcripts were included in the coding and constant comparative analysis. A representative coding tree is provided in Supplementary Table S1. An iterative process was employed throughout, continuously comparing emergent codes, concepts, and categories to verify the robustness of the core category. By the end of February 2026, additional interviews no longer generated new categories, properties, or substantive theoretical relationships, indicating theoretical saturation. Following completion of data collection, futher focused coding, category refinement, constant comparison, and theoretical integration of the complete dataset continued in March 2026. Memos were written throughout the analytical process to enhance reflexivity and transparency. In March 2026, following completion of the preliminary data analysis, summaries of the preliminary findings and core interpretive statements were returned to participants in Mandarin Chinese for member checking to assess whether the interpretations were consistent with their lived experiences.

Results

A total of 21 couples participated in this study. The ages of the patients with COPD ranged from 57 to 80 years, and those of their partners ranged from 47 to 78 years. The participant characteristics are presented in Table 1. The first round of interviews lasted between 20 and 43 min. Follow-up interviews lasted between 3 and 8 min.

Table 1.

Demographic Characteristics of the Participants

Patient ID	Sex	Age	Educational Level	Occupation	Regular Physical Activity	Smoking Status	FEV1/FVC	FEV1 (%) Predicted	GOLD Stage	O2 Use	Exacerbations within One Year	BBQ-AA Score	Partners ID	Age	Educational Level	Occupation	Duration of Care (Years)
1	Male	59	Junior college	Farmer	Yes	Yes	63.47%	72.38%	2	No	0	14	S1	57	Junior high school	Farmer	3
2	Male	68	Senior high school	Retired	No	Quit smoking for 5 years	52.37%	43.28%	3	Yes	1	19	S2	65	Senior high school	Retired	5
3	Female	80	Primary school	unemployed	Yes	No	56.21%	46.34%	3	No	2	21	S3	77	Junior high school	Farmer	10
4	Female	77	Primary school	unemployed	Yes	Yes	60.26%	63.58%	2	No	1	17	S4	78	Primary school	unemployed	6
5	Female	57	Undergraduate	Teacher	Yes	No	56.73%	56.42%	2	No	0	17	S5	60	Undergraduate	Teacher	1
6	Female	69	Junior college	Retired	No	No	58.42%	47.16%	3	Yes	0	20	S6	71	Secondary vocational school	Retired	10
7	Male	66	Junior college	Self-employed	No	Yes	68.11%	68.5%	2	No	0	15	S7	49	Secondary vocational school	Self-employed	8
8	Male	68	Primary school	unemployed	No	Yes	57.82%	45.63%	3	No	0	22	S8	65	Primary school	unemployed	9
9	Male	72	Secondary vocational school	Retired	Yes	Yes	59.13%	48.24%	3	No	0	23	S9	68	Junior college	Retired	12
10	Female	68	Primary school	unemployed	Yes	No	59.38%	62.71%	2	No	0	17	S10	70	Primary school	unemployed	10
11	Male	67	Senior high school	Retired	No	Quit smoking for 2 years	56.47%	43.56%	3	No	0	19	S11	65	Senior high school	Retired	9
12	Male	61	Senior high school	Retired	No	Quit smoking for 6 years	65.39%	74.18%	2	No	0	16	S12	59	Undergraduate	Teacher	3
13	Male	61	Junior college	Self-employed	Yes	Yes	61.94%	67.28%	2	No	0	15	S13	59	Secondary vocational school	Self-employed	5
14	Male	70	Junior high school	Farmer	Yes	Yes	68.42%	86.35%	1	No	0	13	S14	71	Primary school	Farmer	13
15	Male	63	Junior college	Retired	Yes	Yes	64.92%	89.43%	1	No	0	18	S15	61	Junior college	Retired	3
16	Female	77	Primary school	Farmer	No	Yes	57.06%	46.72%	3	No	1	24	S16	77	Primary school	Farmer	15
17	Male	58	Junior college	Teacher	No	No	58.46%	60.37%	2	No	1	14	S17	56	Primary school	public functionary	2
18	Female	58	Undergraduate	Teacher	No	Yes	61.37%	66.47%	2	No	0	16	S18	62	Secondary vocational school	Self-employed	4
19	Male	69	Primary school	Farmer	No	Quit smoking for 1 years	65.18%	74.92%	2	No	1	18	S19	70	Primary school	Farmer	4
20	Female	62	Junior high school	unemployed	No	No	55.39%	44.18%	3	Yes	2	25	S20	65	Junior high school	Chef	3
21	Female	65	Junior high school	unemployed	No	No	66.21%	76.34%	2	No	0	15	S21	72	Junior high school	unemployed	3

The “Entrapped Together or Moving Through Together” Theory

The core category was conceptualised as “Entrapped Together or Moving Through Together” (Figure 2). This theory captures how dyspnoea-related kinesiophobia becomes embedded in the everyday interactions of COPD patients and their partners, and how couples respond to this kinesiophobia as a shared challenge. The theory comprises three interrelated categories: Kinesiophobia Entering Dyadic Interaction, Divergent Patterns of Dyadic Coping, and Relational Crossroads. These categories describe a dynamic process in which patients’ kinesiophobia of activity-related breathlessness and partners’ concerns about safety become increasingly intertwined. Couples responded through different coping patterns, including joint avoidance, motivational conflict, support mismatch, and the paradox of love. Over time, repeated coping interactions appeared to evolve into two contrasting relational trajectories: being entrapped together, characterised by role medicalisation and alienation, or moving through together, characterised by collaborative response and resilience. Within the proposed theory, these relational states were conceptualised as feeding back into subsequent interactions, potentially strengthening or weakening dyadic kinesiophobia resonance.

Figure 2.

“Entrapped Together or Moving Through Together”: a constructivist grounded theory of dyadic coping with dyspnoea-related kinesiophobia in COPD. The model depicts a dynamic four-stage theoretical process generated from participants’ accounts. First, kinesiophobia enters dyadic interaction through symptom expression-triggered resonance and restriction–protection resonance, becoming increasingly shared within the dyad. Second, couples respond through four divergent patterns of dyadic coping: joint avoidance, motivational conflict, support mismatch, and the paradox of love. Third, repeated coping interactions were conceptualised as contributing to two contrasting relational trajectories. The accumulation of avoidance, conflict, withdrawal, and protective control was associated with movement towards “Entrapped Together,” characterised by role medicalisation and alienation; communication breakthroughs, role reconstruction, and accumulated small successes were associated with movement towards “Moving Through Together,” characterised by collaborative coping and resilience. Finally, within the proposed theory, these relational states were conceptualised as feeding back into subsequent interactions, potentially strengthening or weakening dyadic kinesiophobia resonance. The arrows indicate that dyadic coping was conceptualised as an iterative and evolving process rather than a fixed linear sequence.

Kinesiophobia Entering Dyadic Interaction

Interview data revealed that breathlessness-related kinesiophobia gradually entered dyadic interaction rather than remaining an individual experience. Through these dyadic interactions, breathlessness-related kinesiophobia gradually evolved into a shared concern within the couple. Within the proposed theory, this process was conceptualised as occurring through two distinct patterns of dyadic resonance. In one pattern, patients’ expressions of breathlessness were described as evoking partners’ perceptions of movement-related danger. In the other, partners’ protective vigilance was perceived as shaping patients’ own perceptions of movement-related danger. Although these patterns originated from different starting points, both transformed movement-related fear into a shared concern between couples. The conceptual characteristics of these two patterns of dyadic kinesiophobia resonance are summarised in Table 2.

Table 2.

Conceptual Comparison of the Two Patterns of Dyadic Kinesiophobia Resonance

Conceptual Feature	Symptom Expression-Triggered Resonance	Restriction-Protection Resonance
Interactional starting point	Patient expression of symptom-related distress and perceived threatduring or in anticipation of physical activity	Partner concern about perceived risk associated with the patient’s physicalactivity
Predominant starting direction	Patient → Partner	Partner → Patient
Central interactional process	Symptom-related distress is communicated within the dyad andbecomes emotionally shared by the partner	Protective concern is expressed through heightened monitoring, caution,or restriction and becomes embedded in the patient’s appraisal of movement-related risk
Characteristic dyadic response	Emotional resonance with the patient’s symptom-related fear	Protective vigilance and activity restriction
How kinesiophobia becomes dyadic	The patient’s kinesiophobia becomes increasingly shared through the partner’s emotional resonance with symptom expression	The patient increasingly internalises the partner’s movement-related concerns, embedding kinesiophobia within the dyadic interaction

Symptom Expression-Triggered Resonance

Analysis of the interview data revealed that patients’ descriptions of breathlessness symptoms frequently marked the initial point at which breathlessness-related kinesiophobia became shared between patients and their partners. These descriptions were not mere information transmission but functioned as emotional signals laden with suffering and uncertainty capable of directly penetrating their partner’s psychological defences. When patients employed vivid and intense language to depict their bodily sensations in emotionally charged narratives, their partners instantaneously received and interpreted this information as imminent danger alerts, prompting immediate protective anxiety and fear.

1. “As soon as I walk fast or go up a slight slope, I cannot catch my breath. My throat wheezes like a bellows, and my chest tightens. Every time this feeling comes, my heart skips a beat—I know it’s happening again and have to stop immediately” (Patient, male, Dyad 2)

2. “When he describes that ‘wheezing like a bellows’ and ‘chest tightness’, I can almost see the pain he’s in right before my eyes. This isn’t saying ‘I’m tired’; it’s telling me his body is failing!” (Partner, female, Dyad 2)

Restriction–Protection Resonance

Partners’ overprotective sensitivity constituted an alternative pathway through which breathlessness-related kinesiophobia became shared within the couple. Partners continuously monitored patients for even subtle physiological changes, pre-emptively interpreting them as potential risk signals and translating their concerns into anticipatory verbal reminders or behavioural restrictions. Patients were passively situated within this “monitoring–restricting” interaction, in which their own judgments and perceptions of their physical state were increasingly influenced by their partners’ anxious responses. Ultimately, patients described gradually internalising their partners’ concerns, which appeared to reinforce their own breathlessness-related kinesiophobia.

• 3.“I don’t need him to tell me he’s uncomfortable The moment I see his breathing rhythm quicken even slightly, every alarm in my body goes off” (Partner, female, Dyad 7)
• 4.“Sometimes I just feel a bit tired, and she immediately says in a very tense voice, ‘See, I told you you shouldn’t have walked this far!’ That actually makes me start to doubt myself: have I unknowingly already exceeded the danger limit?” (Patient, male, Dyad 7)

Regardless of whether breathlessness-related kinesiophobia originated from patients’ symptom expressions or partners’ protective vigilance, the proposed theory suggests that both resonance processes contributed to the development of kinesiophobia as a shared concern within the couple. As movement became increasingly interpreted through this shared perception of risk, physical activity gradually shifted from an individual behaviour to a dyadic challenge that both patients and partners had to respond to in everyday life. This shared concern formed the basis for the divergent patterns of dyadic coping described in the following category.

Divergent Patterns of Dyadic Coping

Joint Avoidance

Joint avoidance was conceptualised as arising from a mutually reinforced response to anticipated movement-related risk shared by both partners. Both individuals shared a catastrophic imagination of the future, regarding inactivity as the safest, most uncontroversial option. The patient’s decision appeared to be grounded in catastrophic interpretations of bodily signals and a profound fear of losing control; the partner’s decision appeared to reflect trust in the patient’s descriptions, memories of witnessed trauma, and the anxiety associated with the partner’s protective role. Importantly, this shared orientation towards avoidance reflected mutual agreement between partners. Patients and partners discussed their concerns about physical activity and came to a shared decision that reducing or avoiding activity was the safer option.

• 5.“I’m not lazy, I’m afraid of the ‘what if’. As soon as I sense even a hint of risk, I tell my wife I don’t feel like moving today” (Patient, male, Dyad 2)
• 6.“We’ve developed a kind of tacit understanding. We just glance at each other and almost simultaneously say, ‘Let’s do it another day.’ It’s an unspoken safety plan, even though we know it probably means giving up on normal life again” (Partner, female, Dyad 2)

As similar interactions were repeated over time, couples repeatedly adopted avoidance, with joint avoidance gradually becoming established as their habitual dyadic coping strategy for managing perceived movement-related risk. Instead of reassessing each situation independently, inactivity gradually became the default response whenever uncertainty or breathlessness was anticipated.

• 7.“There are almost no spontaneous activities in our house anymore. Everything has to be assessed beforehand. We both seem to have accepted this” (Patient, male, Dyad 8)
• 8.“Avoidance has become our habit, even our way of showing concern…. We’re trapped in a comfort zone built on safety, and neither of us dares to step out first” (Partner, female, Dyad 8)

Motivational Conflict

In some couples, coping with dyspnoea-related kinesiophobia manifested as a persistent tug-of-war between conflicting intentions. This conflict appeared to reflect different temporal and emotional orientations toward risk and recovery: patients were deeply immersed in the fear of immediate physical suffering, while their partners were preoccupied with the responsibility of maintaining the patient’s long-term functional capacity. This divergence in perspective—between “present-moment experience” and “future-oriented consideration”—generated sustained tension characterised by one partner pushing and the other resisting. Consequently, couples struggled to develop a shared coping response, with each partner advocating a different course of action. Underlying this “tug-of-war” was also a negotiation of influence over movement-related decisions. Patients grounded their position in their direct bodily experience of breathlessness and their sense of autonomy over whether to continue or stop an activity, whereas partners drew influence from their caregiving responsibility and concern about the patient’s long-term functional decline. Thus, the conflict concerned not only whether the patient should remain active, but also whose appraisal of immediate safety and longer-term recovery should guide movement-related decisions.

• 9.“Family always say I need to move, but they have no idea what it actually feels like. It’s not tiredness; it’s suffocation. The thought of deliberately throwing myself back into that feeling makes every cell in my body scream ‘no’.” (Patient, female, Dyad 6)
• 10.“Watching her strength decline day by day fills me with desperation. I’m not pushing her; I’m terrified! I’m afraid that if I don’t insist, I’ll just watch her waste away.” (Partner, male, Dyad 6)
• 11.“Whenever she urges me to go for a walk, a wave of irritation washes over me. I feel she does not understand me. She’s never experienced that suffocating, blacking-out despair, has she? So she can glibly say, ‘It’s for your own good’, while I am the one who has to actually endure the suffering.” (Patient, male, Dyad 9)
• 12.“There’s this invisible tug-of-war between us. I am pulling towards health, wanting him to walk even just a hundred metres more each day, but he’s tugging towards comfort, just wanting to lie around. I say it’s for his good, he thinks I am tormenting him. I feel so helpless.” (Partner, female, Dyad 9)

As these goal discrepancies played out repeatedly, persuasion and refusal became entrenched as emotionally depleting adversarial interactions. Partners’ attempts to encourage or supervise activity could increasingly be experienced by patients as pressure, while patients’ refusal could become a means of reasserting control over their own movement decisions. Physical activity was no longer experienced merely as a health behaviour, but came to be experienced as a relational battleground in which both partners struggled to have their fear, concern, and intentions recognised.

• 13.“The mere mention of ‘activity’ changes the atmosphere immediately. I unconsciously slip into this stern, supervisor-like posture. Something that should be mutually supportive ends with his silence and my sighs. It feels like we are consuming our patience and intimacy over this.”(Partner, female, Dyad 11)
• 14.“The more she pushes, the less I want to move. It feels like if I move, I’m giving in to her, admitting she’s right. Sometimes I even deliberately stay still just to protest…” (Patient, male, Dyad 11)

Support Mismatch

In some couples, dyadic coping became difficult because patients and partners held different expectations regarding the support required for physical activity. Rather than disagreeing about whether exercise was beneficial, they differed in their perceptions of the conditions necessary for initiating physical activity. Some patients regarded their partner’s companionship as an essential prerequisite for exercising, believing that emotional reassurance and immediate assistance would reduce their fear of breathlessness and increase their confidence to move. In contrast, partners tended to withdraw because they feared being unable to cope with sudden dyspnea or other exercise-related emergencies. Consequently, patients sought support that partners felt unable to provide, with support needs and support provision becoming increasingly mismatched.

• 15.“What I want most isn’t for him to tell me what to do but for him to just be there with me.” (Patient, female, Dyad 10)
• 16.“It’s not that I don’t want to accompany her. I’m afraid she’ll suddenly have trouble breathing and I won’t know how to help. I feel I can’t bear that responsibility, so sometimes I’d rather not start at all.” (Partner, male, Dyad 10)

As this pattern of seeking and avoidance became increasingly established over time, unmet expectations gradually evolved into disappointment, misunderstanding, and emotional distance. Patients became increasingly reluctant to seek companionship, while partners experienced persistent guilt over their inability to provide the expected support.

• 17.“I don’t ask him to accompany me anymore. There seems to be a barrier between us now.” (Patient, female, Dyad 21)
• 18.“I can feel her disappointment, and it makes me terribly guilty. We rarely do things together anymore. It’s like we’ve formed a tacit agreement to avoid this topic that’s so painful for both of us.” (Partner, male, Dyad 21)

Paradox of Love

The dynamics of some of the participating couples illuminated the most profound dilemma regarding coping with kinesiophobia: movement decisions gradually became dominated by protection rather than shared autonomy. Driven by profound love and an absolute sense of responsibility to prevent harm, partners elevate activity restriction to the supreme principle of protection. Deprived of their autonomy, patients perceive not care but a negation of their will and capabilities. Both partners become entrenched in the perceived legitimacy of their own logic—one vows to spare the other from suffering, while the other pleads to be allowed to live like a “normal” person.

• 19.“What I fear most isn’t the breathlessness itself but being sentenced. She’s like a judge, handing down verdicts with her worry: you can’t do this, that’s too dangerous. She isn’t taking my safety; she’s taking my control over my own life.” (Patient, male, Dyad 17)
• 20.“Me, control him? Listen to that! I am using every ounce of my energy to weave him a safety net! My mission is to prevent that situation from ever happening again, even if he ends up hating me for it. I accept that. Letting him take risks would be the ultimate irresponsibility.” (Partner, female, Dyad 17)
• 21.“Love isn’t locking me in a safe. I know he’s afraid, but I’m more afraid of living like this—watching my world shrink down to just the living room and balcony.” (Patient, female, Dyad 20)
• 22.“To outsiders, I might seem like a cold-hearted guard. But they don’t understand that every time I say ‘no’, my heart bleeds.” (Partner, male, Dyad 20)

As the cycle of restriction–compliance or restriction–resistance continued infinitely, the expression of love became completely alienated. Protection rigidified into control, and longing was suppressed into simmering resentment, together contributing to the gradual erosion of the relationship:

• 23.“Everything is pre-emptively ended by those words: ‘it’s for your own good’. We’re polite to each other, but it’s a cold politeness.” (Patient, male, Dyad 12)
• 24.“I’ve turned myself into his ‘seatbelt’, but that warm, companionable feeling between us has faded more and more.” (Partner, female, Dyad 12)

Although these four coping patterns differed in their behavioural and emotional manifestations, they all reflected couples’ attempts to respond to dyspnoea-related kinesiophobia within everyday life. Joint avoidance, motivational conflict, support mismatch, and the paradox of love showed how fear, safety concerns, support needs, and caregiving responsibility became organised within dyadic interaction. Over time, these repeated coping interactions shaped couples’ relational experiences and led them towards different relational trajectories, as described in the next category.

Relational Crossroads

Although couples adopted different patterns of dyadic coping, these coping interactions were rarely isolated events. Instead, repeated responses to dyspnoea-related kinesiophobia gradually accumulated and reshaped everyday interactions, and were conceptualised as contributing to the emergence of distinct relational states. Two contrasting relational trajectories were identified: being entrapped together and moving through together.

Entrapped Together: Role Medicalization and Alienation

In some couples’ attempts at long-term coping, fear-based overprotection gradually transformed the family space into a quasi-medical setting centred on safety management. The patient’s role was reduced from partner to a “sick body” requiring strict surveillance, while the partner’s role transformed from loving partner to an exhausted, ever-vigilant “warden”. This process reflected the “entrapped together” trajectory, in which both partners became caught in roles organised around fear, protection, and control. This medicalisation of roles was not associated with more effective rehabilitation; instead, it was experienced as a state of chronic mental suffocation.

• 25.“I don’t feel like a husband anymore, more like a naughty child. Every moment of my life feels like I’m undergoing ward rounds.” (Patient, male, Dyad 13)
• 26.“My heart is exhausted. I have to be online all the time. I’ve become his head nurse, but I’ve lost my lover.” (Partner, female, Dyad 13)

As this “guardian–ward” relationship solidified, intimate emotional communication increasingly gave way to functional instructions and reports. The family atmosphere became permeated with a cold, “hospitalised” air:

• 27.“Our home is very quiet, very orderly… but it doesn’t feel like a home anymore, just a private nursing station.” (Patient, female, Dyad 21)
• 28.“I take care of her body, but I’ve lost her heart. We’re trapped in our respective roles; she’s the patient, I’m the overseer.” (Partner, male, Dyad 21)

Moving Through Together: Collaborative Response and Resilience

In stark contrast to the couples who gradually became alienated from one another, a subset of couples found a different way out of similar predicaments. Despite experiencing the draw towards joint avoidance, the strains of motivational conflict, the pain of support mismatch, and even the torment of the “paradox of love”, they developed a remarkable capacity for transformation. Through communication breakthroughs, role reconstruction, and the accumulation of small successes, shared fear gradually came to be experienced less as a source of relational constraint and more as a manageable challenge that could be faced together. Couples developed collaborative coping based on mutual respect, trust, and emotional support. This transformation was not a sudden epiphany, but a gradual process that often began with a small turning point and developed as positive experiences accumulated over time.

• 29.“I noticed her standing by the window, watching people walking downstairs. I said, ‘How about I accompany you to stand downstairs for a while?’ We went down and stood there for five minutes. When we went back upstairs, she gently squeezed my hand.” (Partner, male, Dyad 5)
• 30.“He actively offered to come downstairs with me. Just standing there, but it was the first time someone had been with me to face the outside. At that moment, I suddenly felt, maybe I don’t have to carry this alone.” (Patient, female, Dyad 5)

For these couples, a seemingly insignificant “5 min downstairs and several minutes outside” became the crucial points that broke the deadlock.

• 31.“Suddenly, it dawned on me. I can’t be that ‘safety officer’ hiding on the sidelines anymore. I need to try being her ‘teammate.’” (Partner, male, Dyad 5)

This fundamental role shift transformed the patient’s core feeling from the “isolation” of support mismatch to a sense of supported autonomy:

• 32.“We set small goals together now. If I feel I can’t manage, we stop, and he’s not disappointed. He just says, ‘Then let’s try again tomorrow’. This kind of respect makes me feel I’m not a burden; we’re working on it together.” (Patient, female, Dyad 5)

It is noteworthy that couples who achieved collaboration were keenly aware of the temptation of joint avoidance. Their accounts highlighted their ability to recognise how this “safe alliance” eroded their quality of life and to find the courage to take that first tentative step.

• 33.“The first time we reached the second lamppost, we both suddenly laughed. It wasn’t a bitter laugh; it was genuine, like ‘Hey, we did it!’” (Partner, male, Dyad 5)

As this collaborative model was consolidated, a profound and tacit mutual understanding gradually developed through the shared experience of overcoming difficulties.

• 34.“This disease is awful, but it unexpectedly brought us closer. We now have this feeling of having been through thick and thin together.” (Patient, male, Dyad 1)
• 35.“Our relationship feels like it’s been through a kind of tempering. We used to argue about trivial things, but now, facing such a huge difficulty together and still being able to support each other, those little things just don’t matter anymore.” (Partner, female, Dyad 1)

In contrast, repeated shared movement decisions gradually strengthened mutual confidence, enabling couples to transform movement-related fear into collaborative rehabilitation.

Relational States Feeding Back into Dyadic Kinesiophobia Resonance

Crucially, the two relational states—role medicalisation and alienation, and collaborative coping and resilience—were not fixed endpoints. Instead, they became relational contexts within which patients and partners interpreted and responded to subsequent movement-related fear. Within the proposed theory, these feedback processes were conceptualised as potentially strengthening or weakening dyadic kinesiophobia resonance.

Within the “entrapped together” trajectory, role medicalisation and alienation became embedded within a reciprocal cycle of fear, vigilance, and relational tension. Patients sometimes intensified or withheld symptom expressions in response to accumulated frustration, while partners increasingly interpreted these expressions—and even subtle bodily changes—as evidence of danger. Within this pattern of mutual sensitivity, threat perceptions became increasingly salient, while both partners became further entrenched in fear-organised roles.

• 36.“Sometimes, just to spite her, I deliberately make my discomfort sound worse. I always regret it afterward, though.” (Patient, male, Dyad 17)
• 37.“The words he uses to describe his symptoms are getting more and more frightening. It only convinces me that his condition is worse than I thought. I’m constantly on edge.” (Partner, female, Dyad 17)
• 38.“I’m so exhausted it’s become an instinct. This constant tension makes me over-interpret his every move.” (Partner, male, Dyad 18)
• 39.“The silence at home is terrifying. If I so much as clear my throat, his eyes dart over…. It’s got to the point where I don’t even dare breathe normally.” (Patient, female, Dyad 18)

In contrast, within the “moving through together” trajectory, collaborative coping and resilience were conceptualised as part of a positive feedback process through which dyadic kinesiophobia resonance could gradually weaken. Repeated successful experiences strengthened couples’ confidence in their shared capacity to manage activity-related breathlessness. Patients, feeling supported and safe, became less likely to interpret or communicate breathlessness catastrophically, while partners, witnessing patients’ ability to manage symptoms, experienced reduced protective anxiety and became less likely to impose anticipatory restrictions. Both partners gradually came to view breathlessness as a shared but manageable challenge rather than an uncontrollable sign of impending danger. Over time, fear became less dominant in their interactions, and couples’ attention shifted from avoiding movement to collaboratively considering how activity could be undertaken safely and progressively. Trust, shared confidence, and successful experiences thus increased relational flexibility and supported further collaborative coping.

• 40.“Now we can manage short walks together. Every time we succeed, I feel it’s not so much that I’ve managed to control her, but that we’ve achieved it together.” (Partner, male, Dyad 5)
• 41.“Before, whenever I felt unwell, my mind would just go to ‘Oh no, here it comes, I can’t handle it’. Now, I first try the breathing techniques he’s around to help with. I know he’s not here to judge me, he’s here to help, so I do not need to exaggerate how I feel to get attention.” (Patient, female, Dyad 5)
• 42.“Seeing him manage to adjust when he’s uncomfortable, instead of collapsing outright, is the biggest ‘stress relief’ for me.” (Partner, female, Dyad 15)
• 43.“Our discussion isn’t about whether to walk today but about which tree to walk to, and if it feels okay, whether to try an extra five metres. It feels completely different.” (Patient, male, Dyad 15)

Discussion

Kinesiophobia and its aftermath constitute a profound biopsychosocial predicament, the impact of which extends far beyond the initial kinesiophobia itself. The theory of “Entrapped Together or Moving Through Together” conceptualises coping with kinesiophobia in COPD as a dyadic rather than solely individual process, encompassing fear resonance, coping dilemmas, relational divergence, and resilience. By illuminating the dyadic interdependence inherent in kinesiophobia and the divergent pathways of relational evolution, the theory of entrapped together or moving through together challenges pulmonary rehabilitation frameworks to move beyond the limitations of traditional biomedical models. Coping with kinesiophobia therefore involves not only physical functioning but also role reconfiguration, emotional negotiation, and relational meaning.

Existing literature on the mechanisms of dyspnoea suggests that dyspnoea is a multidimensional experience involving physiological, cognitive, and affective factors, with anxiety, catastrophic interpretations, and anticipatory fear shaping how patients perceive and respond to breathlessness.¹² The present study further suggests that kinesiophobia in patients with COPD is not only related to fearful anticipation of breathlessness but may also be shaped through interactions between patients and their partners. This study conceptualises kinesiophobia as relationally embedded, becoming increasingly shared through symptom expression-triggered and restriction–protection resonance and recursively shaped through patient–partner interactions. This pattern of dyadic resonance aligns with a core proposition of family systems theory, which conceptualises the family as an emotional unit in which individual thoughts, feelings, and behaviours are embedded within and reciprocally influenced by an interconnected network of family relationships.³⁷ Within this theoretical account, the partner is therefore not merely a source of support but an active participant in how movement-related fear is interpreted and managed within the dyad. In this way, our findings extend the understanding of dyspnoea-related fear from the individual level to the dyadic context, further illustrating how such fear may be maintained, amplified, or attenuated through interpersonal interaction. These findings suggest that couple-centred approaches may warrant further development and evaluation. Potential strategies informed by the present findings could include routine dyadic assessments of both partners’ fear levels, interaction patterns, and coping mechanisms. Such assessments may help identify interaction patterns associated with “symptom expression-triggered” and “restriction–protection” resonance and could inform the development of interventions aimed at addressing the cyclical amplification of fear and supporting adaptation and recovery. Concurrently, future couple-centred interventions could explore the use of guidance and educational strategies to facilitate couple communication, helping both partners recognise the fear-based logic underlying each other’s behaviours. Furthermore, assessment of the couple’s psychological preparedness to return to their daily activity environment could be considered as a potential component of future discharge planning or stable-phase management, including consideration of the possibility of re-entering fear-organised interaction patterns.

Within the proposed theory, couples responded to kinesiophobia through diverse patterns of dyadic coping, forming the second core category of this study. These patterns can be situated within established theories of dyadic coping. Bodenmann’s systemic-transactional model conceptualises stress and coping as an interpersonal process in which one partner’s stress experience is communicated, appraised, and responded to within the couple, rather than managed solely at the individual level.²⁵ Berg and Upchurch’s developmental-contextual model further situates dyadic coping within chronic illness, emphasising the interdependence of patients’ and partners’ appraisals and coping responses and their variation across relational, illness, and developmental contexts.²⁶ Together, these perspectives provide an important theoretical basis for understanding how dyspnoea-related kinesiophobia may become a shared dyadic challenge. Consistent with these established models, our findings similarly emphasise that coping with illness-related stress is interdependent rather than solely individual. However, the present grounded theory adds disease-specific process detail by illustrating how this interdependence unfolds around movement-related fear in COPD, as couples’ converging or differing appraisals of immediate symptom threat, longer-term functional recovery, protection, and autonomy shape their responses to activity. Joint avoidance, motivational conflict, support mismatch, and the paradox of love therefore represent not simply alternative coping styles, but distinct ways in which couples negotiated movement-related risk and recovery in the context of COPD. Among these, the “paradox of love” represents a profound relational dilemma, in which the intention to protect can, through its entanglement with fear, become a source of constraint. Participants’ accounts suggested that partners’ restrictive behaviours were often rooted in love and a strong sense of responsibility to prevent harm. Such behaviours align with theoretical frameworks concerning overprotection in family psychology,³⁸ where attempts to eliminate risk may provide a sense of security at the cost of the protected partner’s autonomy. In contrast, patients viewed their capacity for activity as closely tied to dignity, social roles, and control over their own lives. Thus, restrictions imposed in the name of safety could be experienced not simply as care, but as a loss of autonomy and self-mastery. The tension between patient protection and patient autonomy revealed in this study therefore adds complexity to existing understandings of overprotection. When activity restriction becomes entrenched, this tension may extend beyond activity decisions to reshape relational roles: patients become increasingly positioned as individuals requiring surveillance, while partners assume a monitoring and protective role. In this process, the home may gradually become organised around safety management, leaving both partners caught in a relational pattern characterised by diminished autonomy for the patient and sustained vigilance and emotional burden for the partner. This dynamic suggests the potential value of developing and evaluating couple-centred psychosocial interventions aimed at addressing conflicting perspectives and supporting couples in negotiating a balance between safety and autonomy. Potential approaches informed by the present findings could include couple-based workshops providing a space for patients and partners to jointly explore the boundaries between protection and autonomy, an issue embodying both vulnerability and relational resilience. Future aftercare approaches could consider not only improvements in the patient’s lung function and exercise tolerance but also the couple’s process of constructing meaning around safety and autonomy. Peer-support approaches for couples with shared experiences may represent another potential avenue for future development and evaluation, allowing couples who have transitioned from “using a safety net” to “standing shoulder-to-shoulder” to share their experiences with others facing similar relational challenges.

The relational divergence identified in this study suggests that kinesiophobia may become embedded in either increasingly alienating or more collaborative patterns of interaction over time. Based on the interactional patterns identified in the present grounded theory, we hypothesise that “role medicalisation and alienation” may adversely affect rehabilitation participation or outcomes; however, this proposed relationship was not examined in the present study and requires prospective investigation. Within our qualitative data, this relational state was characterised by sustained hypervigilance and emotional exhaustion among partners, which resonate with theories of caregiver burden in chronic illness contexts.^39,40 Importantly, however, the burden identified in this study was not unidirectional. Patients’ kinesiophobia and activity avoidance appeared to increase partners’ vigilance, protective responsibility, and emotional strain, while partners’ heightened vigilance and restrictive responses could, in turn, intensify patients’ perceived loss of autonomy and relational distress. This reciprocal process suggests that burden in the context of dyspnoea-related kinesiophobia may be better understood as a dyadic and mutually reinforcing experience rather than solely as caregiver burden. However, the predicament of the partners in this study presents a more complex dimension. Beyond experiencing role alienation through suppressing their emotions and relinquishing intimate interactions, the partners became entangled in experiences resembling moral injury within the “paradox of love”—knowingly perpetuating harmful restrictions yet fearing to relinquish them—lending this dilemma a profoundly tragic character. In stark contrast, the “collaborative coping and resilience” pathway illuminates the potential for relationships to be forged and strengthened within the crucible of crisis. Along this trajectory, couples reframe their shared fear as a challenge to be confronted together. Partners evolve from “wardens” to “coaches”, and patients evolve from being “managed” to being “participants”, progressively building a sense of relational efficacy. This evolution from “relational efficacy” to “relational resilience” aligns closely with the concept of “meaning reconstruction” central to post-traumatic growth theory.⁴¹

More importantly, these two relational states are not endpoints of the interactive journey; rather, they may feed back into subsequent dyadic interactions, reinforcing or attenuating fear resonance over time. Negative relational patterns may sustain hypervigilance, restriction, and avoidance, whereas collaborative coping may weaken fear resonance through growing relational efficacy and shared confidence. This theoretically generated pattern of reciprocal interaction echoes descriptions of “prolonged grief disorder” within theories of non-linear grief.⁴² When trauma remains unprocessed, individuals oscillate repeatedly between grief and adaptation.⁴³ Conversely, within the proposed theory, the collaborative coping and resilience pathway was conceptualised as part of a positive feedback process characterised by diminishing fear and growing relational empowerment. This phenomenon aligns with a core tenet of family resilience theory: crises can be transmuted into opportunities for relationship strengthening.⁴⁴ Importantly, this dynamic feedback process does not occur in isolation but is embedded within the changing clinical course and rehabilitation trajectory of COPD. Pulmonary rehabilitation represents an important context in which this model may intersect with clinical practice. Exercise training repeatedly exposes patients to exertional breathlessness that they may previously have feared or avoided, while also requiring partners to distinguish between expected, manageable responses to exertion and warning signs that warrant activity modification or cessation. Rehabilitation teams could therefore attend not only to patients’ symptoms and exercise capacity but also to how couples jointly interpret and respond to breathlessness, identifying patterns such as joint avoidance, overprotection, and tensions between safety and autonomy. Where such patterns are present, partners could be selectively involved in rehabilitation education and selected exercise sessions to develop a shared understanding of exertional symptoms and safety boundaries and to clarify supportive roles during activity.⁴⁵ Such dyadic assessment could be considered within existing rehabilitation assessment or follow-up processes rather than as a separate component. Acute exacerbations may represent another important turning point in this dyadic process. Symptom deterioration, emergency visits, or hospitalisation may renew perceptions of activity-related danger and reactivate fear, hypervigilance, and protective restriction that had previously diminished. Reassessment during post-exacerbation follow-up or when pulmonary rehabilitation is resumed may therefore help identify how couples interpret the exacerbation in relation to activity, whether new patterns of joint avoidance or overprotection have emerged, and where support is needed to rebuild shared confidence in symptom management and activity resumption. As COPD progresses, changes in breathlessness, exercise tolerance, and functional status may further alter couples’ perceptions of activity-related risk and safety boundaries. Previously established activity goals and supportive roles may therefore require adjustment, with couples repeatedly renegotiating the balance between activity participation, protection, and patient autonomy. Taken together, these considerations suggest that dyadic interaction patterns may warrant reassessment at clinically meaningful transition points, including entry into pulmonary rehabilitation, recovery following an exacerbation, and substantial changes in functional status, with dyadic rehabilitation support adjusted accordingly. These findings highlight the potential value of ongoing professional support for patients with COPD and their partners throughout the rehabilitation journey and provide a basis for developing flexible, couple-centred interventions responsive to changing clinical and relational needs. However, these clinical implications are derived from the present theoretical model and findings, and their feasibility and effectiveness across different pulmonary rehabilitation settings require prospective evaluation.

Limitations

Despite its notable findings, this study has several limitations. First, although theoretical sampling was employed to capture a diverse range of couple interaction patterns, the exploration of within-sample heterogeneity was limited. As couples with different educational backgrounds and economic circumstances, as well as at different stages of illness, may exhibit variations in coping strategies, future research should explore the influence of these variables on the dyadic coping process. Second, the inclusion of participants capable of providing rich narrative data may have resulted in a sample weighted towards couples with stronger expressive abilities and a greater willingness to share personal and relationship experiences with the researchers. Consequently, the perspectives of couples who were highly sensitive about the privacy of their relationship or less willing to disclose relationship experiences to the researchers may have been underrepresented. Future studies should purposively include such couples to achieve a more comprehensive understanding of dyadic coping experiences in this population. Third, because the interviews were conducted dyadically with both partners present, joint-interview reactivity cannot be excluded. Participants may have moderated, withheld, or reshaped accounts of sensitive relational experiences, particularly those involving conflict, control, or resentment, in response to their partner’s presence. Future studies combining joint and separate interviews may help capture perspectives that are less readily expressed in a dyadic setting. Fourth, this study focused on patients with COPD and their partners within a single cultural context, which may limit the transferability of the findings. Cross-cultural comparative research would be valuable for evaluating the generalisability of the theoretical framework. Fifth, depression and anxiety were not formally assessed. As these symptoms may coexist with dyspnoea-related kinesiophobia and contribute to activity avoidance, the present study could not examine their potential relationships or interactions. Future studies should incorporate validated measures of depression and anxiety to further clarify these relationships. Finally, although the grounded theory conceptualises dyadic coping as an evolving process involving feedback between relational states and subsequent interactions, the data were derived primarily from single-time-point interviews in which participants retrospectively narrated their experiences over time. Therefore, the temporal sequence and feedback relationships identified in the proposed theory represent theoretical processes generated from participants’ retrospective accounts rather than longitudinally observed trajectories. Future longitudinal qualitative studies involving repeated interviews with couples are needed to examine how these dyadic processes unfold and change over time.

Conclusion

Coping with kinesiophobia due to COPD is not merely an individual psychological adjustment process for the patient but a dynamic journey wherein couples continuously negotiate between safety and autonomy, collaboratively recalibrating their relationship and its shared meanings. By centring on the couple as the fundamental unit of coping, this study highlights the potential value of moving beyond traditional models that compartmentalise biomedical and psychosocial interventions and of exploring couple-centred approaches that may help transform fear-based interactions into relational resources. Rather than establishing a separate intervention pathway, these approaches could potentially be embedded within existing pulmonary-rehabilitation structures. Brief dyadic screening for fear, joint avoidance, overprotection, and safety–autonomy tensions could be incorporated into the initial rehabilitation assessment and reassessed at clinically meaningful transition points, such as following an exacerbation or substantial change in functional status. Rehabilitation nurses or other appropriately trained members of the multidisciplinary team could provide brief couple-focused education and communication support during existing education or follow-up sessions, while peer-support platforms could potentially be integrated into existing group-based or follow-up services. Such integration may reduce the need for additional standalone services; however, its feasibility will depend on local staffing, time, training, and rehabilitation capacity and should be evaluated before routine implementation. However, these implications should be interpreted within the scope of the present exploratory qualitative study. The effectiveness of these potential couple-centred approaches was not evaluated and therefore warrants prospective evaluation, while the single-centre, single-region setting limits the transferability of the findings to other populations and clinical contexts.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Abbreviations

COPD, Chronic Obstructive Pulmonary Disease; ERS, European Respiratory Society; ATS, American Thoracic Society; GOLD, Global Initiative for Chronic Obstructive Lung Disease; BBQ-AA, Activity Avoidance subscale of the Breathlessness Beliefs Questionnaire; RA, Research Assistant.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.