Scared for the scar: fearsome impact of acute cardiovascular disease on perceived kinesiophobia (fear of movement)

Abstract

Background

To assess levels of kinesiophobia (fear of movement) in patients hospitalized for acute cardiovascular disease.

Hypothesis

Increased levels of kinesiophobia can be found in subjects hospitalized for acute cardiovascular disease.

Methods

Seventy‐four consecutive patients admitted for acute coronary syndrome and 58 for acute heart failure were enrolled in the study and assessed by the Tampa Scale for the evaluation of kinesiophobia. Subjects were compared with a reference population with stable coronary artery disease and healthy controls.

Results

No significant differences were found between acute coronary syndrome and acute heart failure in terms of kinesiophobia, even considering the rates of high kinesiophobia (Tampa score >37) and the 4 groups of questionnaire items (danger, fear, avoidance, dysfunction). Differences, however, were significant comparing our population with an historical population of subjects with stable coronary artery disease and controls (43 ± 5 vs 35 ± 7 vs 33 ± 6, P < 0.0001 in both cases). A significant correlation was found between the grade of kinesiophobia in the Tampa Scale and the age of subjects (r = 0.27, P = 0.001) and inversely with level of education (r = −0.33, P < 0.0001).

Conclusions

Increased levels of kinesiophobia can be found in subjects hospitalized for acute cardiovascular disease. Kinesiophobia is related to age and education. Kinesiophobia should be carefully considered in subjects hospitalized in acute cardiac care units.

1. INTRODUCTION

Episodes of acute cardiovascular (CV) disease requiring emergency room access and admission to an acute cardiac care unit are usually followed by a significant humoral and psychological impact.1, 2, 3 Anxiety and depression following an episode of acute CV disease may further negatively influence the prognosis in patients with CV disease.4 Nevertheless, hospitalization of subjects with prior chronic disease could have a reducing effect on kinesiophobia/fear of movement due to access to all caring resources. The global impact of hospitalization and the individual's perceived new condition of chronic CV disease, however, may be modulated by non‐CV conditions such as familial condition, age, and education.5

Self‐rated health is an important risk marker after myocardial infarction (MI), and its long‐term evolution is related to demographic, socioeconomic, clinical, and psychosocial variables.6 However, residual kinesiophobia is not just a negative state of mind, afflicting patients with acute CV disease during the hospitalization; subjects who are “scared for the scar” may fail to follow the finalized program of CV rehabilitation, which are ideally indicated after every acute episode of CV disease and which are programs shown to reduce CV mortality and readmission.7

The fear of future possible limitations in normal daily mobility because of CV sequelae or residual pain, therefore, has not been well investigated in patients hospitalized for acute CV disease. In the present study, we thus sought to assess the perceived impact of hospitalization for acute CV disease in terms of self‐rated limitation in mobility and fear for pain after discharge (kinesiophobia), and to compare subjects hospitalized for acute coronary syndrome (ACS), acute heart failure (AHF), and controls.

2. METHODS

2.1. Study population

We evaluated 160 consecutive patients admitted to the acute cardiac care unit at the Department of Cardiology, Riuniti Hospital, University Hospital of Foggia, Foggia, Italy, from July 2015 to October 2015, for any episode of ACS or AHF. Of these, 6 patients with ACS and 22 with AHF wished not to participate in the study, so the final number of patients enrolled was 74 for ACS and 58 for AHF. Results were compared with a reference population of subjects with and without stable coronary artery disease (CAD).8

Perceived fear of present or future limitation in mobility and/or of pain associated with mobility were assessed by submitting a 17‐item questionnaire oriented at exploring kinesiophobia. Questionnaires were given at admission and gathered at discharge. The Italian translation of the Tampa Scale for Kinesiophobia (TSK) Heart was used for measuring kinesiophobia.9 The TSK Heart comprises 17 items that assess the subjective rating of kinesiophobia. Each item is rated on a 4‐point Likert scale, with scoring alternatives ranging from “strongly disagree” to “strongly agree.” A total sum is calculated after reversion of items 4, 8, 12, and 16. The total score varies between 17 and 68. A high value indicates a high level of kinesiophobia. The TSK Heart includes 4 constructs: 2 behaviorally oriented constructs—avoidance of exercise and dysfunctional self—concerning possible irrational perceptions and beliefs about rehabilitation, and 2 constructs concerned with beliefs and mental imaginations—perceived danger for heart problem and fear of injury. The TSK Heart has been found to be reliable and valid for patients with CAD.9 Vlaeyen et al defined a cutoff of >37 as a high level of kinesiophobia.10

All patients underwent clinical examination; age, gender, medical history, and CV risk factors were recorded. Nonclinical variables such as education (1 lower, 2 intermediate, 3 higher) and living alone or with anyone were recorded.

The study was conducted according to the Declaration of Helsinki and, given its observational nature, did not require approval by local ethics committee. All patients gave a written informed consent.

2.2. Statistical analysis

Continuous variable were reported as means ± standard deviation and compared with an analysis of variance test, dichotomic variables as were reported as percentage and compared with χ² test or Fisher exact test as required. Correlations were analyzed with the Pearson test.

Multivariable analysis was used to assess the bias from principal confounders. A P value <0.05 was considered as statistically significant.

3. RESULTS

The population's characteristics are given in Table 1. The mean Tampa score values were 43 ± 5 in the whole population; 83% of subjects had a Tampa score >37, the mean age was 60 ± 12 years, 18% were living alone, 35% were female, 67% were hospitalized for the first time for an ACS or AHF, 35% were smokers, 33% were diabetics, and 40% were hypertensive.

Table 1.

Population's characteristics and comparison between subjects with acute coronary syndrome and acute heart failure

	Population, N = 132		Acute Coronary Syndrome, N = 74		Acute Heart Failure, N = 58		P
	Mean	Std. Dev.	Mean	Std. Dev.	Mean	Std. Dev.
Tampa score	43.1	5.5	43.8	5.4	42.3	5.5	0.1116
Tampa score >37	83%		86%		79%		0.2757
Danger items	10.7	1.5	10.8	1.6	10.5	1.2	0.2384
Fear items	9.9	2.1	9.9	2.1	9.9	2.3	0.8885
Avoidance items	12.3	1.8	12.5	1.9	12.0	1.7	0.1055
Dysfunction items	10.3	2.3	10.6	2.2	9.9	2.4	0.0959
Age	60.2	11.8	60.7	11.7	59.5	11.9	0.5596
Living alone	18%		12%		26%		0.0432
Education level (1–3)	1.8	0.8	1.8	0.8	1.8	0.8	0.8085
Female	35%		35%		34%		0.9384
First hospitalization for acute cardiovascular disease	67%		70%		62%		0.3249
Smoking habit	35%		31%		40%		0.3085
Diabetes	33%		32%		34%		0.8059
Hypertension	40%		42%		38%		0.6480

Abbreviations: Std. Dev., standard deviation.

No significant differences were found between ACS and AHF in terms of kinesiophobia, even considering the rates of high kinesiophobia (Tampa score >37) and the 4 groups of items (danger, fear, avoidance, dysfunction). Differences, however, were significant comparing our population with an historical population of subjects with stable CAD and controls (43 ± 5 vs 35 ± 7 vs 33 ± 6, P < 0.0001 in both cases, +23% vs stable CAD, +30% vs controls) (Figure 1).

Figure 1.

Kinesiophobia levels assessed by Tampa score (reference population from Koho et al6). Abbreviations: n.s., not significant.

A significant correlation was found between the grade of kinesiophobia in the Tampa scale and the age of subjects (r = 0.27, P = 0.001) and, inversely, with level of education (r = −0.33, P < 0.0001) (Figures 2 and 3). Correlations remained significant even after evaluation at multivariable analysis considering age, gender, education, diagnosis, and index hospitalization as the first hospitalization. No significant differences were found when considering gender or living alone.

Figure 2.

Correlation between kinesiophobia assessed by Tampa test and age (r = 0.27, P = 0.001).

Figure 3.

Correlation between kinesiophobia assessed by Tampa score and education levels (r = 0.33, P < 0.0001).

4. DISCUSSION

To the best of our knowledge this is the first article evaluating the early impact of hospitalization for acute CV disease (ACS, AHF) on kinesiophobia. We found increased perceived levels of kinesiophobia in subjects hospitalized for acute CV disease when compared with stable CAD and healthy controls. Differences between subjects with ACS and AHF were not statistically significant. We originally compared the impact of several clinical conditions on perceived levels of kinesiophobia. According to our findings, levels of kinesiophobia during a hospital stay for an episode of acute CV disease are significantly impacted by age and education, but not by gender and familial status.

Prior data have been published on CV subjects with CAD in its stable phase5, 11 and in subjects implanted with a cardioverter/defibrillator.12 A high level of kinesiophobia can be found in 20% of patients with CAD11; attending cardiac rehabilitation, level of physical activity, general health, and physical functioning are usually related to lower levels of kinesiophobia, whereas HF as a complication at the hospital and anxiety are usually related to higher levels of kinesiophobia. Not unexpectedly, chronic CV conditions such as chronic HF were related to lower levels of kinesiophobia. Presumably, the limiting effect of acute CV episodes is more impactful than chronic conditions, whose elaboration is facilitated by time.

Up to one‐third of patients with AHF present with ACS. Compared to non–ACS‐AHF patients, ACS‐AHF patients are more likely to be older males; present with de novo HF; have severe left ventricular systolic dysfunction; have multivessel coronary artery disease; have a history of ischemic heart disease, diabetes, dyslipidemia; and are less likely to have chronic kidney disease.13 During a hospital stay, ACS‐AHF patients are more likely to develop shock and recurrent HF, need more mechanical ventilation, and receive β‐blockers and angiotensin‐converting enzyme inhibitors, and in‐hospital mortality is significantly higher. Whereas medical history and the manifestation and initial treatment of AHF between ACS‐AHF and non–ACS‐AHF patients differ, long‐term survival is similar.14

High levels of kinesiophobia have been found also in several other groups of non‐CV patient, such as those with chronic low back pain, fibromyalgia, osteoarthritis, and upper extremity disorders.15, 16

Hospitalization for ACS had a major negative impact on patient lifestyle and return to work, irrespective of the underlying cardiac diagnosis.17 In 160 subjects hospitalized for ACS, 62% saw themselves as heart patients after hospitalization for ACS; quality of life was perceived to have decreased in 44%, self‐image in 53%, and self‐confidence in 49%. Anxiety was reported by 54%, and the anxiety level was high. Only 49% of patients who were working prior to the acute event returned to full‐ or part‐time gainful employment. For several patients, an acute MI can induce post‐traumatic stress disorder.18

Illness representation is also important in influencing the prognosis. Anxiety, independent of depressive symptoms, is associated with in‐hospital cardiac complications after acute MI.19 In patients with acute MI, illness representation was predictive of the likelihood of experiencing a complication.20 After adjustment for demographic and clinical factors, as well as depression, high perceived stress was associated with a 3‐fold increased risk of 30‐day readmission after an ACS episode.21 Perceived personal experience during a hospital stay has been shown to condition the evolution of psychological stress.22

Abrupt smoking cessation may further expose patients admitted with ACS symptoms to higher levels of psychological stress23; after adjusting for age, smokers experience significantly higher overall levels of stress, depression, anxiety, and anger than nonsmokers during a hospital stay for ACS.

Kinesiophobia should therefore be acknowledged in subjects in the early phase of acute CV disease and carefully assessed to identify more fragile subjects needing specialized and individualized intervention for secondary prevention. In a study on 62 patients with a first episode of ACS24 compared with controls, patients attending exercise‐based cardiac rehabilitation led by a registered physiotherapist demonstrated higher levels of fear‐avoidance beliefs at baseline, which decreased over time. Furthermore, attendees increased their level of physical activity and exercise over time. In 332 patients with a diagnosis of CAD, bypass grafting and a diagnosis of ST‐elevation MI increased the probability of attendance at exercise‐based cardiac rehabilitation, whereas kinesiophobia reduced attendance.25 As a mediator, kinesiophobia was influenced by 4 predictors, and the following indirect effects were found. General health and muscle endurance increased the probability of attendance at cardiac rehabilitation, whereas self‐rated anxiety and current incidence of heart failure had the opposite effect. This study suggests that kinesiophobia has an influence on and a mediating role in attendance at exercise‐based cardiac rehabilitation. Participation in exercise‐based cardiac rehabilitation is therefore strongly recommended for patients with MI, especially those with increased fear of movement.

5. CONCLUSION

Increased levels of kinesiophobia can be found in subjects hospitalized for acute CV disease. Kinesiophobia is related to age and education. Kinesiophobia should be carefully considered in subjects hospitalized in acute cardiac care units.

5.1. Limitations

These are preliminary data coming from an observational study, needing to be confirmed in a larger cohorts of patients. No data are available on several other factors potentially influencing levels of kinesiophobia during hospitalization (number of prior hospitalizations, prior levels of kinesiophobia, ischemic vs nonischemic HF), thus possibly reducing the extensibility of results.

Comparison between acute CV patients and controls has been done comparing 2 different populations; several bias factors may have influenced the results.

Conflicts of interest

The authors declare no potential conflicts of interest.

Brunetti ND, Guerra A, Ieva R, Correale M, Santoro F, Tarantino N and Di Biase M. Scared for the scar: fearsome impact of acute cardiovascular disease on perceived kinesiophobia (fear of movement), Clin Cardiol, 2017;40:480–484. 10.1002/clc.22682