Abstract

Background:

Kinesiophobia is a significant psychological factor that affects early ambulation in postoperative patients. It is particularly common after radiofrequency ablation for atrial fibrillation. Nonetheless, few studies comprehensively or systematically explore how physical, psychological, and disease-related objective factors predict kinesiophobia.

Objective:

The primary aim of this study is to examine the level of kinesiophobia and its contributing factors among patients following radiofrequency ablation for atrial fibrillation. This research aims to provide clinical evidence for the development of targeted intervention strategies to reduce motor phobia. These strategies aim to boost patients’ motivation and adherence to early physical activity, ultimately improving cardiac health post-surgery.

Methods:

A cross-sectional survey was conducted, assessing patients using questionnaires, including the Tampa Scale for Kinesiophobia Heart, Self-efficacy for exercise Scale, the Perceived Social Support Scale, the Fried Frailty Phenotype Scale, the Generalized Anxiety Disorder-7, the Patients’ Health Questionnaire Depression Scale, Physiological indicators related to atrial fibrillation, and echocardiographic examinations. Univariate and multivariate regression analyses were used to investigate the factors influencing kinesiophobia. The difference was considered statistically significant at p < 0.05.

Results:

The study included 356 patients. Multiple linear regression analysis identified the following influencing factors: frailty (β = 0.168: 95% CI, 0.606 ~ 1.375), LAD (β = 0.048: 95% CI, 0.007 ~ 0.077), LVEF (β = −0.117: 95% CI, −0.124 ~ −0.057), past history of stroke (β = 0.178: 95% CI, 1.919–4.126), combined heart failure (β = 0.182: 95% CI, 1.549–3.283), EHRA symptom classification (β = 0.121: 95% CI, 0.575–1.340), disease course (β = 0.075: 95% CI, 0.272–0.965), disease recurrences (β = 0.062: 95% CI, 0.023–1.843), perceived social support (β = −0.309: 95% CI, −0.225 ~ −0.137), and GAD-7 (β = 0.443: 95% CI, 0.651–0.939). These factors significantly influenced kinesiophobia in patients after radiofrequency ablation of atrial fibrillation (p < 0.05). They accounted for 86.4% of the total variance in kinesiophobia.

Conclusion:

Multiple factors influence kinesiophobia in patients after radiofrequency ablation for atrial fibrillation. Healthcare providers should prioritize risk assessment and individualized rehabilitation plans while fostering a support system that includes psychological care, family, and social resources to reduce kinesiophobia and support a safe resumption of daily activities.

1 Introduction

Atrial fibrillation (AF) represents the most prevalent persistent arrhythmia encountered in clinical practice. In recent years, the prevalence, incidence, and mortality associated with atrial fibrillation in China have shown a consistent upward trend (1, 2). The atrial fibrillation management guidelines endorse radiofrequency ablation as the first-line electrophysiological treatment modality (3). This approach effectively diminishes the burden of atrial fibrillation, sustains sinus rhythm, enhances cardiac function, and reduces mortality. Its clinical benefits surpass those of conventional pharmacological treatments (4). Nevertheless, the rates of recurrence and readmission following the procedure remain relatively high (5).

In recent years, cardiac rehabilitation programs that emphasize exercise have become part of managing atrial fibrillation. Studies show that exercise-based rehabilitation is safe and effective, improving cardiovascular health after radiofrequency ablation (3). These programs can enhance exercise endurance, lower resting heart rate, alleviate anxiety and depression, and improve overall quality of life (6). The European Association for Cardio-Thoracic Surgery also found that regular exercise is associated with a lower risk of atrial fibrillation recurrence (7). Although many benefits have been confirmed, the exercise participation rate of patients after radiofrequency ablation for atrial fibrillation is low, and their compliance is poor (1, 8).

Kinesiophobia was first used to assess the degree of musculoskeletal pain (9). Heart disease kinesiophobia is described as a fear of physical activity or exercise due to the fear that activity or exercise may worsen the condition and cause other adverse cardiovascular events. Bäck et al. (10) and Keessen et al. (11) found that cardiac rehabilitation compliance declines as patients’ fear of exercise increases. Multiple studies report that fear of movement affects 57–74% of patients with atrial fibrillation (8, 11, 12). This fear prevents patients from engaging in physical exercise. As a result, patients adopt passive avoidance behaviors, which decrease their activity levels and further lower their quality of life (13). Therefore, it is necessary to investigate the factors influencing Kinesiophobia in these patients to provide a basis for subsequently formulating targeted intervention strategies.

Although existing studies have explored the influencing factors of Kinesiophobia in patients after atrial fibrillation ablation. Ding et al. (8) and Li et al. (14) mainly analyzed demographic characteristics (age, educational level, income level) and disease-related factors (disease course, symptom classification), but rarely included biochemical indicators and objective examination data such as echocardiography. At present, there is still a lack of systematic research on developing a comprehensive model of influencing factors that integrates physiological, psychological, and social factors. Therefore, this study aims to comprehensively incorporate psychological, social, and physiological indicators related to atrial fibrillation, echocardiography-assisted examinations, and other factors, investigate the current status of kinesiophobia in patients after radiofrequency ablation of atrial fibrillation, and deeply analyze its influencing factors, with the aim of providing a basis for formulating targeted intervention strategies and reducing patients’ Kinesiophobia.

2 Methods2.1 Design and study population

This is a cross-sectional study that utilized a convenience sampling method to select subjects. Patients diagnosed with atrial fibrillation who underwent radiofrequency ablation surgery in the Department of Cardiovascular Medicine at a tertiary hospital in Hubei Province between December 2024 and December 2025 were selected as participants. Statistical analysis was conducted on data from 356 patients. Inclusion criteria were as follows: (1) compliance with the diagnostic criteria for atrial fibrillation as outlined in the ESC Guidelines for the management of atrial fibrillation (15); (2) age of 18 years or older; (3) Three months after the completion of radiofrequency catheter ablation (RFCA), there were no serious postoperative complications; (4) provision of informed consent for participation in the study. Exclusion criteria included: (1) Those with a clear diagnosis of severe mental illness (such as schizophrenia, bipolar disorder, etc.), or those with cognitive impairment who are unable to complete the questionnaire; (2) contraindications for motor function tests.

2.2 Sample

In this study, the sample size was estimated based on the influencing factors related to kinesiophobia in atrial fibrillation Patients. According to the empirical formula for multivariate analysis sample-size estimation, sample size (N) = number of study factors (n) × (10~15). A total of 27 independent variables were included in this study, so the required sample size was calculated to be at least 270. A total of 380 questionnaires were subsequently distributed, and 356 valid questionnaires were recovered (effective recovery rate, 93.68%). The reasons for the 24 invalid/unrecovered questionnaires included: patient transfer to another hospital (n = 6); The questionnaire was incomplete or had logical errors (n = 10); Incorrect contact information or rejected calls (n = 8).

2.3 Data collection

This study was a cross-sectional descriptive study conducted on-site at an atrial fibrillation outpatient center 3 months after atrial fibrillation surgery. After the informed consent forms of the research participants were received, professionally trained researchers distributed questionnaires to the patients and explained their content, the purpose of the study, and how to complete the questionnaire. If any issues regarding the completion method or questionnaire content, the researcher would immediately return it to the participant for correction.

2.4 Measurements2.4.1 General information questionnaire

The general situation questionnaire was designed by the researchers based on previous studies and included demographic data. Age, gender, marital status, educational level, income, occupation, medical insurance; Disease-related information: Disease course, recurrence, past medical history, EHRA symptom classification, concomitant medication, physiological indicators related to atrial fibrillation (N-terminal pro-B-type Natriuretic Peptide, NT-proBNP), high-sensitivity cardiac troponin I, hs-cTnI. Echocardiography-assisted examinations (left ventricular ejection fraction, LVEF; left atrial diameter, LAD).

2.4.2 Tampa scale for kinesiophobia heart (TSK-SV heart)

The scale, originally developed by Bäck et al. (16) was subsequently translated into Chinese. It comprises four dimensions: perception of danger (items 3, 8, 11, 16), fear of movement (items 2, 4, 12, 14, 17), avoidance of movement (items 1, 7, 9, 13), and dysfunction (items 5, 6, 10, 15). This scale uses a 4-point Likert scale, with items 4, 8, 12, and 16 reverse-scored, yielding a total possible score of 17–68. Higher scores indicate greater severity of motor phobia; a total score exceeding 37 points indicates a high level of motor phobia. The scale demonstrates strong internal consistency, as evidenced by a Cronbach’s alpha coefficient of 0.882. In this study, the scale demonstrated a Cronbach’s alpha coefficient of 0.828.

2.4.3 Self-efficacy for exercise

This scale, originally developed by Resnick and Jenkins (17) and subsequently translated into Chinese by Lee et al. It consists of 9 items, each rated on a scale from 0 to 10. The scoring is based on the mean of these 9 items, with higher scores indicating greater exercise self-efficacy. The scale demonstrated a Cronbach’s alpha of 0.874. In this study, the scale demonstrated a Cronbach’s alpha coefficient of 0.923.

2.4.4 Perceived Social Support Scale

This scale originally developed by Zimet et al. (18) and subsequently translated into Chinese by Jiang Ganjin. It consists of three dimensions: family, friends, and support from others, encompassing a total of 12 items. It employs a 7-point Likert scale, yielding a total score ranging from 0 to 84 score, with higher scores indicating a greater perceived level of social support. The scale demonstrates a Cronbach’s alpha coefficient of 0.896. In this study, the scale demonstrated a Cronbach’s alpha coefficient of 0.945.

2.4.5 Fried frailty phenotype

The scale was proposed by Professor Fried in 2001 (19) and consists of five indicators: unexplained weight loss, self-reported fatigue, reduced physical activity, decreased walking speed, and low grip strength. Assessed through self-assessment questionnaires and objective measurements, respectively. The threshold values for physical strength, walking speed, and grip strength are stratified based on gender, height, and body mass index (BMI), respectively. This scale assigns 1 point for each frailty indicator met, with a total score of 0 to 5. A higher score indicates greater frailty severity. Chinese researchers have translated and applied this assessment tool into Chinese, demonstrating its scientific validity.

2.4.6 Generalized Anxiety Disorder-7

This scale was developed by Spitzer et al. (20) in 2006 and subsequently translated into Chinese by He Xiaoyan. It comprises 7 items that assess factors such as tension and anxiety, the degree of worry, the extent of relaxation, and the ability to remain still, among others. The assessment uses a 4-point Likert scale, yielding a total score ranging from 0 to 21. Higher scores indicate greater severity of the patient’s anxiety condition. The scale demonstrates a Cronbach’s alpha coefficient of 0.898. In this study, the scale demonstrated a Cronbach’s alpha coefficient of 0.891.

2.4.7 Patients’ Health Questionnaire Depression Scale-9

The scale, originally developed by Wang et al. (21), was subsequently translated into Chinese by Bian Cuidong. It comprises 9 questions and uses a 4-point Likert scale, yielding a total score range from 0 to 27. Higher scores indicate greater severity of the patient’s depression. The scale demonstrates a Cronbach’s alpha coefficient of 0.857. In this study, the scale demonstrated a Cronbach’s alpha coefficient of 0.815.

2.5 Ethical and research approvals

This study received approval from the Ethics Committee of Wuhan Central Hospital (Approval Number: WHZXKYL2024-266-01). All participants consented to participate in this study and provided written informed consent. All methods were carried out in accordance with relevant guidelines and regulations.

2.6 Statistical methods

Data entry and analysis were performed using SPSS Statistical 26.0. Measurement data were reported as M ± SD, and count data as frequencies and composition ratios (%). For non normally distributed measurement data were presented as median and quartile [P50 (P25, P75)]. To examine the influence of general information on exercise fear, t-tests and ANOVA were conducted. Next, correlations among frailty state, social support, psychology and exercise fear were assessed using Pearson’s correlation. Subsequently, variables that were significant in either the univariate or the correlation analyses were selected as independent variables (p < 0.05) with the TSK-SV Heart score as the dependent variable in multiple linear regression. Finally, p < 0.05 indicated statistical significance.

3 Results3.1 Basic participant characteristics

The ages of the 356 patients ranged from 33 to 87 years; 49.16% (n = 175) were male, and 50.84% (n = 181) were female. A total of 76 patients (21.35%) had a primary school education or lower, 107 (30.06%) had a junior high school education, 111 (31.18%) had a high school education, and 62 (17.41%) had a college degree or higher. Approximately 3.93% (n = 14) of the patients had a monthly household income per person below ¥2,000. Table 1 shows the sociodemographic characteristics of study participants.

VariablesN (%)TSK-SV heart scorest/FPGender0.718a0.473Male175 (49.16)43.39 ± 6.06Female181 (50.84)42.93 ± 5.88Domicile−0.770a0.938City344 (96.63)(38.00 49.00)Rural area12 (3.37)(36.25 49.00)Occupation0.791b0.532Retire177 (49.72)43.33 ± 5.89Peasant21 (5.90)43.52 ± 5.87Worker22 (6.18)42.91 ± 6.35Cadre15 (4.21)40.53 ± 6.11Other121 (33.99)43.21 ± 6.04Educational level0.280b0.840Primary school and below76 (21.35)43.22 ± 5.77Middle school107 (30.06)43.47 ± 5.93Senior middle school111 (31.18)42.75 ± 5.89University62 (17.41)43.27 ± 6.48Personal monthly income (yuan)0.062b0.940<2,00014 (3.93)43.14 ± 5.992,000–4,000192 (53.93)43.06 ± 5.18>4,000150 (42.14)43.29 ± 6.19Payment method0.022a0.882Private16 (4.49)43.38 ± 6.24Medical insurance340 (95.51)43.25 ± 5.97Smoking−1.289a0.198Yes66 (18.54)42.30 ± 5.76No290 (81.46)43.35 ± 6.09Drinking alcohol−0.250a0.802Yes33 (9.27)42.91 ± 6.26No323 (90.73)43.18 ± 5.95Concurrent hypertension−0.380a0.704Yes212 (59.55)(38.00 49.00)No144 (40.45)(38.00 48.00)Concurrent diabetes mellitus−0.732a0.464Yes76 (21.35)(38.00 50.00)No280 (78.65)(38.00 48.00)Concurrent coronary disease−0.617a0.537Yes122 (34.27)(38.00 49.00)No234 (65.73)(38.00 49.00)Combined heart failure20.737a<0.001Yes100 (28.09)50.22 ± 2.73No256 (71.91)40.40 ± 4.42Past history of stroke13.961a<0.001Yes51 (14.33)51.84 ± 0.95No305 (85.67)41.70 ± 5.17Types of atrial fibrillation−1.405a0.161Paroxysmal atrial fibrillation220 (61.80)42.82 ± 6.22Persistent atrial fibrillation136 (38.20)43.71 ± 5.51Disease course (years)25.370b<0.001<3103 (28.93)41.4 ± 6.263–5169 (47.47)42.45 ± 5.28>584 (23.60)46.86 ± 5.35EHRA symptom classification81.550b<0.001116 (4.50)43.31 ± 6.832a189 (53.09)39.81 ± 4.092b110 (30.90)46.82 ± 4.42341 (11.51)49.15 ± 6.0840 (0)–Concurrent medications (types)1.480a0.140<316 (4.49)45.31 ± 5.72≧3340 (95.51)43.06 ± 5.97Disease recurrences−3.353a0.001Yes69 (19.38)45.29 ± 6.02No287 (80.62)42.64 ± 5.85

General characteristics of after radiofrequency catheter ablation in patients with atrial fibrillation (n = 356).

3.2 Univariate analysis of kinesiophobia after radiofrequency catheter ablation in patients with atrial fibrillation

The total kinesiophobia score in atrial fibrillation patients 3 months after surgery was (43.16 ± 5.97), with 71.63% at a high level of kinesiophobia, scores of each dimension: perception of danger (9.62 ± 1.76), fear of movement (12.04 ± 2.06), avoidance of movement (9.94 ± 1.66), and dysfunction (9.30 ± 2.01). The univariate analysis revealed statistically significant differences in kinesiophobia scores among patients with atrial fibrillation for past history of stroke, past history of heart failure, duration of atrial fibrillation, EHRA symptom classification, and recurrence status (p < 0.05; see Table 1). The above statistically significant factors were included in the multiple linear regression analysis.

3.3 Correlation analysis of kinesiophobia after radiofrequency catheter ablation in patients with atrial fibrillation

The findings from the correlation analysis indicated that fried frailty phenotype (FFP), generalized anxiety disorder-7 (GAD-7), patients’ health questionnaire depression scale-9 (PHQ-9), NT-proBNP, LAD, and hs-cTnI showed significant positive correlations with the level of kinesiophobia (p < 0.001). Conversely, self-efficacy for exercise (SEE), perceived social support scale (PSSS), and LVEF demonstrated significant negative correlations with the level of kinesiophobia (p < 0.001), see Table 2.

ItemsScoresTSK-SV heart scoresrPFFP(2.0 3.0)0.819<0.001SEE3.57 ± 0.95−0.815<0.001PSSS55.50 ± 0.54−0.837<0.001GAD-74.52 ± 0.170.848<0.001PHQ-97.03 ± 0.190.734<0.001NT-proBNP206.21 ± 9.800.768<0.001LEVF58.12 ± 0.41−0.234<0.001LAD39.49 ± 0.360.1170.014hs-cTnI(0.001 0.030)0.872<0.001

Correlation analysis of kinesiophobia after radiofrequency catheter ablation in patients with atrial fibrillation.

Fried frailty phenotype (FFP); Self-efficacy for exercise (SEE); Perceived Social Support Scale (PSSS); Generalized Anxiety Disorder-7 (GAD-7); Patients’ Health Questionnaire Depression Scale-9 (PHQ-9); N-terminal pro-B-type Natriuretic Peptide (NT-proBNP); high-sensitivity cardiac troponin I (hs-cTnI); left ventricular ejection fraction (LVEF); left atrial diameter (LAD).

3.4 Multiple linear regression analysis of the influencing factors kinesiophobia after radiofrequency catheter ablation in patients with atrial fibrillation

In the preliminary regression model, multicollinearity was detected for NT-proBNP (VIF = 6.068) and Self-efficacy for exercise (SEE) (VIF = 7.292), exceeding the conventional threshold of 5. PHQ-9 score, though marginally below the threshold (VIF = 4.968), was nonsignificant (p = 0.602) and conceptually overlapped with anxiety. To avoid bias in the estimation of regression coefficients and ensure model stability, this study eliminated the three variables listed above and refitted the model. With these adjustments completed, the VIF values of all independent variables in the final model were <5 (range: 1.068–2.886; tolerance > 0.4), indicating no multicollinearity and a stable, reliable model. Residual diagnosis shows that normality, homoscedasticity, independence, and linearity are all satisfied, and the Cook distance is less than 1. There are no strong influence points, and the regression hypothesis is valid. The final analysis results show that factors such as frailty, LAD, LVEF, Past history of stroke, Combined heart failure, EHRA symptom classification, Disease duration, Disease recurrences, Perceived Social Support, and anxiety significantly influenced kinesiophobia in patients after radiofrequency ablation of atrial fibrillation (p < 0.05). These factors accounted for 86.4% of the total variance in kinesiophobia (see Table 3).

VariablesBSEβ95% CItPVIFConstant37.0002.835–31.42542.57613.053<0.001–FFP0.9910.1950.1680.6061.3755.072<0.0012.863hs-cTnI0.1810.2660.0160.1040.3420.6820.4961.354LEVF−0.0910.017−0.117−0.124−0.057−5.337<0.0011.252LAD0.0420.0180.0480.0070.0772.3860.0181.068EHRA symptom classification0.9570.1940.1210.5751.3404.924<0.0011.584Past history of stroke3.0220.5610.1781.9194.1265.386<0.0012.801Combined heart failure2.4160.4410.1821.5493.2835.479<0.0012.886Disease course0.6190.1760.0750.2720.965