By Anna Horner | News & Views

The fear of physical movement and activity can prevent cardiovascular and pulmonary rehabilitation (CR/PR) participants from making progress in their recovery, say Diann Gaalema, PhD, FAACVPR, and Katherine Menson, DO. That’s why, they explain, providers must be able to recognize exercise- and movement-related anxiety in patients.

In a 40^th AACVPR Annual Meeting session titled “Kinesiophobia: Understanding Fear of Exercise as a Barrier in Cardiopulmonary Rehabilitation,” Drs. Gaalema and Menson, along with clinical psychologist Samantha Farris, PhD, will explain the effects of this condition and how to support patients so they can get the most out of their CR or PR prescription. “We want clinicians to understand that these symptoms exist and have impacts on health outcomes and use that knowledge to optimize outcomes for people entering CR or PR programs,” says Dr. Gaalema (pictured left). “We want patients in rehab to move, and if they’re afraid to move, it’s obviously going to impact their outcomes. It’s important that we ask, ‘How do we help people when they’re afraid to do the things we know they need to do to get better?’”

Dr. Menson explains that CR and PR programs can incorporate aspects of models in other rehabilitative therapies, such as comprehensive pain programs and programs for people with chronic lower-back pain. “There's so much mental remodeling that happens to avoid pain or the perception of discomfort,” she says. “It’s important to understand that fear from a patient perspective. Are there better ways that we can target it and break through that mindset a little bit? We can look at how other models are doing that and how they're providing the delivery of care in other disease states as well.”

In cardiac rehab, Dr. Gaalema says one of the main concerns among patients is the fear of reinfarction, with patients worried that exercising or moving will cause them to have another event. “When we bring people in to do their entry stress test, for example, and you have them on the treadmill working relatively hard and can see that everything's fine, that they're doing okay, then that is probably helpful,” she says. “But some of the issue around exercise is that there are overlaps of symptoms between exercising and symptoms that may have preceded their events, such as shortness of breath or feeling sweaty, flushed, or dizzy. These are bodily sensations that may mimic some of the things they associated with their initial event but are likely just normal responses to exercise.”

For patients in pulmonary rehab, Dr. Menson (pictured right) stresses that progressive discomfort and anxiety-provoking symptoms are not typically from an acute event but from little events that have been progressive over time and gone unnoticed. “Classically, what patients will tell us is they've stopped washing their hair or putting things in the upper cabinets because using their arms distracts the accessory muscles of breathing that they've come to rely on,” she explains.

“Someone with healthy lungs generally uses those muscles only with moderate-to-intense activity, but these patients have been using them every day. So it’s important to help them first understand that they've made these micro adaptations and then realize they're going to have to face that discomfort to get the muscles of breathing stronger and their heart and lungs stronger. It’s not about breaking through this event that obviously comes with a lot of trauma but stopping habits that have formed over a long period of time.”

According to Dr. Gaalema, across both CR and PR is the fear of falling among older adults, which also impacts their desire to move, even outside of rehab. Dr. Menson says, “This is why it’s important to assess the patient’s fears and goals and model their exercise prescription accordingly. Helping them overcome their fears and achieve their goals in a safe and supportive environment will help them go on to do it themselves successfully.” Dr. Gaalema adds, “You don't want to make people feel dependent upon being in CR or PR, where they feel safe because they are being monitored. This is where you need to build people up so that they feel safe outside of rehab.”

The session will not only identify clinical psychology interventions that can help improve outcomes but also equip clinicians with strategies to recognize that these fears are a concern for patients. “Bringing attention to kinesiophobia will help clinicians understand whether this is something that's happening in their patient population,” Dr. Gaalema says. “Then they will learn what they can specifically do in their programs to help these patients.” Dr. Menson adds, “Maybe patients are too scared to exercise and not willing to admit it. It’s important for providers to recognize that this may be the reason why a patient isn’t progressing or is showing other behaviors, such as not participating in the program or avoiding certain exercises. Having that understanding and using the tools Dr. Farris will provide will help clinicians push through that.”