Cardiovascular disease is a major public health problem worldwide, characterized by high morbidity and high mortality, and is the leading killer of human health (Benjamin et al., 2019), which will increase the heavy burden on individuals and social medical and health service system (Cook et al., 2014; The Writing Committee Of China, 2023). More than 64 million people worldwide suffer from heart failure (Savarese et al., 2023). Cardiac exercise rehabilitation originated in the 1960s (Clausen et al., 1969), which is a comprehensive rehabilitation strategy consisting of five prescriptions including drugs, exercise, nutrition, psychology (including sleep management), smoking cessation and alcohol restriction. Many guidelines recommend exercise rehabilitation for patients with cardiovascular disease (Ponikowski et al., 2016; Sharma et al., 2021). For example, the ‘Ten Commandments’ for the 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease clearly state that “All able individuals with cardiovascular disease should engage in at least 150 min of exercise per week divided over 5 days, or 75 min of vigorous exercise divided over 3 days” (Sharma et al., 2021). Kinesiophobia is defined as an excessive, irrational sense of vulnerability to sports or daily activities due to a reduced threshold of the body to pain due to injury such as pain (Vlaeyen et al., 1995), it is also known as fear of movement, and so on. Changes in cardiac structure and decreased cardiac output in heart failure patients contribute to respiratory muscle atrophy, exacerbating dyspnea (Nakagawa et al., 2020). Concurrently, pulmonary congestion and infection further compromise lung function, resulting in symptoms such as coughing and expectoration (Douillet et al., 2023). These combined factors significantly diminish the quality of life for affected patients. Kinesiophobia can exacerbate dyspnea and lead to discomfort such as chest tightness and palpitations. Furthermore, it can increase psychological stress and negative emotions in patients (Qin J-. W. et al., 2022; Tang et al., 2023), reducing treatment compliance and posing a major obstacle to participation in exercise-based cardiac rehabilitation for heart failure patients (Rogerson et al., 2012). Exercise rehabilitation has been proven to be an effective secondary prevention measure for patients with Chronic Heart Failure (CHF). It serves as a cornerstone and crucial component of cardiac rehabilitation, offering numerous benefits to patients, as evidenced by studies (Pelliccia et al., 2021; Youn et al., 2023). Studies have shown that kinesiophobia is one of the key factors for non-adherence to home-based cardiac rehabilitation in patients with chronic heart failure (Yang et al., 2023a,b). Despite the growing body of research on kinesiophobia, there is a lack of systematic reviews that have comprehensively outlined the influencing factors of kinesiophobia in patients with chronic heart failure. Therefore, the aim of this commentary is to delineate the current influencing factors of kinesiophobia in patients with chronic heart failure and identify potential research gaps to address future research needs in this area. Our review addresses two key research questions: (a) What is the prevalence of kinesiophobia in patients with chronic heart failure? (b) What are the factors that influence kinesiophobia in patients with chronic heart failure?

While we applied the scoping review methodology proposed by Arksey and O'Malley (2005) and advanced by Levac et al. (2010), we did not perform the sixth step, i.e., consultation, because we examined the study related to the influencing factors of kinesiophobia in patients with chronic heart failure, we did not address the perspectives of other stakeholders on this issue.

The current situation of kinesiophobia in patients with chronic heart failure is not optimistic. According to existing studies, the level of kinesiophobia in patients with chronic heart failure reaches 54.40–69.50% (Qin J. et al., 2022; Qin J-. W. et al., 2022; Sentandreu-Mano et al., 2023; Tang et al., 2023; Zhang et al., 2023). The current research in this field is mainly concentrated in China, with less research in other regions, which to some extent reflects the insufficient attention paid to CHF-related anxiety in other regions. Our research shows that the current studies are mostly cross-sectional surveys, lacking comprehensive policy guidance or targeted interventional studies. Our study indicates that the assessment tools for CHF-related anxiety are mostly subjective questionnaires, lacking objective assessment indicators or tools, which highlights the importance of medical and nursing staff assessing the level of CHF-related anxiety in a timely manner and developing suitable objective assessment tools in the future, which will improve the accuracy of assessment and promote the achievement of cardiac rehabilitation for CHF patients.

The study review conducted in this study revealed 19 factors that affect kinesiophobia in patients with CHF, which can be categorized into four thematic categories. Among them, the socio-demographic factors and disease and treatment factors themes contain the most factors, with 7 factors each. It is worth noting that although our study categorized the factors affecting kinesiophobia in patients with CHF into four themes, each theme is not independent and can interact with each other. The factors of social support in the socio-demographic factors domain and comorbidity factors in the disease and treatment domain are closely associated with mental health. Social support encompasses emotional, informational, and tangible aid from various sources such as family, friends, and the community (Langford et al., 1997). Effective social support can significantly alleviate patients’ psychological distress, including depression (Patra et al., 2017). Additionally, an increase in the number of complications can elevate the risk of depression (Wiltink et al., 2011). Social support can also enhance patients’ access to medical information. Patients who heavily rely on social support tend to leverage the social resources available to them to acquire disease-related information through various channels (Qiao et al., 2021). Furthermore, social support directly influences self-efficacy (Liu et al., 2023). Patients with high self-efficacy are confident enough to actively engage in postoperative rehabilitation training, thereby establishing and adopting healthy behaviors, enhancing compliance with treatment, and developing skills for health self-management to promote cardiac rehabilitation.

Among all these factors, educational attainment has proven to be the most prevalent influencing factor, indicating a significant effect on kinesiophobia. Patients with higher levels of education demonstrate greater abilities in acquiring disease-related information and self-management skills (Qiao et al., 2021). This, in turn, empowers them to make informed decisions. Conversely, CHF patients with lower educational backgrounds may lack a comprehensive understanding of their condition, potentially leading to fear of early functional exercise and resistance to early rehabilitation training. Consequently, the optimal rehabilitation window may be missed, thereby impacting patient rehabilitation. This underscores the importance of giving increased attention to CHF patients with lower educational backgrounds in clinical settings. Implementing targeted interventions or health education based on the educational level of CHF patients holds significant value.

Low-income CHF patients often face significant financial burdens, worrying that engaging in physical activity may exacerbate their condition and escalate medical costs. Thus, they often resort to avoidance and passive coping strategies in managing daily activities and functional exercises. However, employment not only offers financial stability but also fosters social interaction, structure, and a sense of accomplishment, all of which can alleviate symptoms of kinesiophobia.

Social status is a position within society determined by an individual or group’s access to resources, including income, education, occupation, and other factors (Bradley and Corwyn, 2002). It encompasses both objective measures and subjective perceptions, with subjective social status more accurately influencing life attitudes, behaviors, and future expectations (Goodman et al., 2003). Subject social status (Zhang et al., 2023) exhibited a negative correlation with kinesiophobia (p < 0.05). Higher social status affords greater resources, social recognition, and influence, thereby enhancing individual well-being and mental health (Adler et al., 2000).

Coping style serves as a cognitive behavioral strategy individuals employ to effectively manage internal and external stressors. Patients adopting a positive coping style are more likely to exhibit psychological resilience to adverse reactions, thereby optimizing health outcomes and improving quality of life. Conversely, individuals inclined towards negative responses may lack confidence and succumb to ineffective outcomes, exacerbating health consequences. Patients with multiple comorbidities often exhibit reduced tolerance for self-exercise and are prone to avoidant coping, leading to diminished motivation for physical activity. Consequently, patients with lower activity levels are more susceptible to developing kinesiophobia. Despite the myriad benefits regular activity and exercise offer, such as enhanced physical functioning, improved sleep quality, and better management of negative emotions (Chakravarty et al., 2008), individuals grappling with kinesiophobia often fail to fully leverage these advantages. This limitation, in part, presents a challenge to cardiac rehabilitation in CHF patients.

While existing studies have highlighted associations between social status, disease awareness, coping mechanisms, surgical history, comorbidities, and kinesiophobia in CHF patients, further research is needed to deepen our understanding of these factors. Future studies should comprehensively explore these aspects to inform effective intervention measures. Accurate assessment of exercise fear in heart failure patients is pivotal for promoting exercise rehabilitation. Although various versions of exercise fear assessment scales exist and have been applied in diverse populations, researchers must carefully select the most suitable research tool considering regional and population characteristics to accurately gauge the level of exercise fear in future studies.

In general, the 9 studies (Hoffmann et al., 2018; Dai et al., 2022; Qin J. et al., 2022; Qin J-. W. et al., 2022; Chen and Li, 2023; Qin et al., 2023; Sentandreu-Mano et al., 2023; Tang et al., 2023; Zhang et al., 2023) included in this study can reflect the influencing factors of the occurrence of kinesiophobia in patients with chronic heart failure, and provide a basis for the development of clinical targeted nursing measures. However, only part of the studies have conducted follow-up, which may cause bias in the study results. Secondly, on the issue of kinesiophobia, most of the studies included in this study were analyzed from the patients themselves, and there were certain limitations in the perspective of discussion. In addition, kinesiophobia is a dynamic process, and long-term follow-up of patients is needed to evaluate the impact of kinesiophobia on cardiac rehabilitation. To effectively reduce or mitigate the fear of movement in patients with CHF, a comprehensive approach is necessary, encompassing multidisciplinary professional interventions and governmental policy support, particularly for economically disadvantaged patients. Given the chronic nature of CHF and its prolonged treatment process, patients often bear a substantial disease burden, making appropriate medical subsidies or relief crucial. Hence, future research should adopt a multifaceted approach, examining various perspectives, including those factors or populations currently underrepresented. A thorough exploration of targeted interventions for kinesiophobia is paramount. Additionally, further research is warranted to investigate the long-term effects of kinesiophobia on the cardiac rehabilitation outcomes of CHF patients.

The reviewers encountered challenges related to language barriers, resulting in the consideration of only published Chinese or English. There may also be a certain degree of selection bias present. The reviewers did not reach out to the researchers involved in this study for additional relevant information, potentially leading to some missing data. Furthermore, the methodological quality of the studies included was not systematically evaluated. Lastly, the assessment instrument utilized in these studies consisted of a self-report questionnaire and lacked objective measures of kinesiophobia, suggesting potential bias in the reported levels.

Patients with chronic heart failure have a high incidence of kinesiophobia and many influencing factors, but the current research is not comprehensive. In the future, more clinical interventions can be further carried out based on the results of existing research to reduce the incidence of kinesiophobia in patients with chronic heart failure and promote the realization of cardiac rehabilitation based on exercise rehabilitation.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

QX: Writing – original draft, Writing – review & editing. X-YX: Conceptualization, Funding acquisition, Supervision, Writing – review & editing. M-JZ: Data curation, Formal analysis, Writing – review & editing. SL: Data curation, Formal analysis, Resources, Writing – original draft. HC: Methodology, Supervision, Writing – review & editing. M-DL: Data curation, Formal analysis, Writing – review & editing. YW: Methodology, Resources, Software, Writing – review & editing. YY: Resources, Supervision, Writing – review & editing.