Management of Venous Access Port to Overcome Kinesiophobia of Patients with Malignant Tumors: A Review

Background

According to a World Health Organization report, the number of new patients with malignant tumors in China reached 4 568 000 in 2020. With the aging of the population, the number of patients with malignant tumors is increasing in China [1]. Patients with malignant tumors need to undergo long-term chemotherapy. Repeated venipuncture and chemotherapeutic drugs make patients prone to phlebitis, which affects the treatment process and therapeutic effect [2]. The implantable venous access port (VAP) is a type of intravenous infusion device implanted under the skin and consists of 2 parts: a catheter holder and a catheter. Compared with traditional infusion devices, implantable VAP can reduce the incidence of phlebitis. It also can be left in place for a long period of time and has less impact on the daily life of patients. VAP is often used in patients with poor peripheral venous access. Since the first report of a fully implantable VAP in 1982, the use of VAPs in the treatment of patients with malignant tumors has substantially increased [3]. However, patients undergoing infusion port implantation are prone to fear of resuming daily life activities. Patients frequently experience kinesiophobia due to local pain, foreign body sensation, and other discomforts caused by the implants [4], which in turn exacerbates their anxiety and slows the recovery of postoperative physical functions [5]. Research on kinesiophobia in China is still in its infancy, and the relevant literature mostly focuses on lumbar spine diseases and arthroplasty [6,7]. In this paper, we reviewed the research status, assessment tools, and coping strategies of kinesiophobia in patients with malignant tumors and VAP. This study can provide a reference for medical personnel to prevent and alleviate kinesiophobia in patients with malignant tumors and VAP, thereby improving patients’ quality of life.

Literature Search Strategy

Using the combination of subjective words and freedom words, and based on literature traceability methods, China National Knowledge Infrastructure (CNKI), Wanfang, Vipp, Chinese Biomedical Database (CBM), Web of Science, The COCHRANE LIBRARY, Embase, and PubMed were searched. The detection strategy was (cancer* OR tumor* OR neoplasm*OR sarcoma*) AND (implantable venous access port OR implantable venous access device* OR totally implantable venous access device* OR TIVAD OR implantable venous access port OR IVAP OR infusion port OR venous port access* OR VPA OR catheter-related OR CRT) AND (Kinesiophobia* OR fear of movement OR fear of reinjury, panic disorder OR pain catastrophizing OR fear avoidance). All articles from the construction of the database to October 30, 2023 could be included.

The Concept of Kinesiophobia

Lethem et al [8] proposed the FA model in 1983, indicating that the different behaviors adopted by patients after perceiving physical pain can affect their physical recovery. These findings laid the basic theoretical foundation for research on kinesiophobia by later scholars. In 1990, Kori et al named this fear of movement and the adopted behavior kinesiophobia [9]. Their paper explained that under specific conditions, patients become more sensitive to pain, and patients wrongly judge that body movement can exacerbate the pain and injury. Thus, due to hypervigilance, patients avoid movement, which negatively impacts their functional and physical recovery. In 2012, Hu et al first defined “kinesiophobia” as “the fear of any movement” [10]. In a recent study [11], the psychological structure associated with the “fear-avoidance” model was analyzed through network analysis and the effect of psychological variables on the fear of movement score was explored. This study utilized the Swedish Quality Registry for Pain Rehabilitation, including data from 10 436 participants, the degree of perceived pain was found to be positively correlated with the fear of movement score. Fang et al reported that the process of learning to perceive fear has a greater impact on patients’ fear of pain. The article also indicated that kinesiophobia is related to how the family can support and influence patients [12].

Studies on Kinesiophobia: In China and Abroad

Studies on kinesiophobia were first conducted by non-Chinese researchers. Based on the “fear-avoidance” model, the knowledge about their own disease, related causal concepts, timeline beliefs, attitudes toward treatment, prejudice to the outcome, and several other psychological factors are involved in kinesiophobia of people with chronic pain [13]. Cultural context was also introduced as an influencing factor [14]. Literature related to kinesiophobia has focused on patients with low back pain [15] and total knee replacement [16], exhibiting a positive correlation between pain perception and kinesiophobia. Vaegter et al [17] showed the correlation between kinesiophobia and pain intensity through an exercise intervention in 54 patients with chronic musculoskeletal pain. The intensity of pain in patients with severe kinesiophobia was significantly higher than that in patients with mild kinesiophobia. The understanding of kinesiophobia is gradually expanding. For example, Paula et al [18] explored the occurrence of kinesiophobia in patients with malignant tumors after the use of peripherally inserted central catheters (PICC). Patients experienced anxiety and fear in the post-PICC period. Salim et al [19] conducted a study on kinesiophobia in postmenopausal women with osteoporosis and found that the fear of falling, psychological status, self-efficacy, and other factors affect their kinesiophobia. There are few studies on kinesiophobia from China. In a study by Tan et al [20], 304 elderly patients with knee osteoarthritis were included in 2 hospitals in Northwest China. The prevalence of kinesiophobia was higher among these patients. It was found that demographic and sociological factors such as marriage, education, and pain affected their kinesiophobia. Wang et al [4] showed that 45.7% of patients with malignant tumors using VAP had mild kinesiophobia and 18.4% had moderate to severe kinesiophobia. Among patients with malignant tumors using VAP, the probability of suffering from kinesiophobia is higher. Although most of them experience mild kinesiophobia, it should still be a great concern for healthcare professionals and patients.

Assessment Tools for Kinesiophobia Among Patients with Malignant Tumors Using VAPs

TAMPA SCALE FOR KINESIOPHOBIA (TSK):

The Tampa Scale for Kinesiophobia (TSK) is widely used in the assessment of kinesiophobia. It has 17 questions, each scored between 1 and 4. The final score ranges from 17 to 68, with higher scores indicating more severe kinesiophobia [21]. In 2015, Wei et al [22] collected and analyzed data from 142 patients with low back pain in mainland China. The results showed Cronbach’s α of 0.74 and 0.82 and retest reliabilities of 0.86 and 0.90. They used the simplified Chinese version of the Tampa Scale for Kinesiophobia (SC-TSK) to assess the severity of kinesiophobia. They used 2 different forms of SC-TSK, one containing 17 questions and the other containing 13 questions. The study confirmed the reliability and validity of the SC-TSK. Thus, it facilitated the application of the TSK and SC-TSK for clinical research in mainland China. In the study of Cai et al [23], a simplified version of TSK, the TSK-11, was localized, translated, and applied to patients undergoing total knee arthroplasty. The results showed that the simplified Chinese version of the TSK-11 has a Cronbach’s α of 0.883. Its retest confidence level was 0.798, demonstrating that the simplified Chinese version of the TSK-11 can effectively assess Chinese patients’ fear of moving around.

FEAR AVOIDANCE BELIEFS QUESTIONNAIRE:

The Fear Avoidance Beliefs Questionnaire (FABQ) was proposed by Waddell et al [24] in 1993 based on the theory of “fear-avoidance” to study the effects of fear-avoidance beliefs on low back pain and disability. The FABQ consists of 16 items, each rated between 0 and 6. The total score can be between 0 and 96, with higher scores showing a more severe fear of movement. The FABQ has been widely used and translated into Japanese [25], Finnish [26], and other languages. It has a high Cronbach’s α and retest confidence. Thus, it can be effectively used in clinical settings in different countries. In 2012, Hu et al [10] evaluated the reliability and utility of the simplified Chinese version of the FABQ. The Cronbach’s α and retest confidence levels of the simplified Chinese version of the FABQ were 0.888 and 0.949, respectively. It also proved that the simplified Chinese version of the FABQ has a high degree of validity and reliability.

CANCER FATIGUE SCALE:

The Cancer Fatigue Scale (CFS) measures the degree of cancer-related fatigue (CRF) caused by the disease and related treatments. CRF is divided into 2 categories: unidimensional and multidimensional categories [27]. A concise three-dimensional self-assessment CFS was developed by Toru et al [28]. Data from 300 patients indicated that the internal consistency and validity of this type of CFS were satisfactory. In 2004, Wang et al [29] conducted a study on the Chinese version of the Brief Cancer Fatigue Scale (BFI-C). The Cronbach’s α of the BFI-C on the fatigue severity item was 0.92. The correlation analysis of data from 249 Chinese patients confirmed the high reliability of the BFI-C. In 2018, Chan et al [30] investigated the feasibility of the Multidimensional Cancer Fatigue Scale-Short Form (MFSI-SF) in Asian breast cancer patients. The results demonstrated the clinical relevance of the MFSI-SF for studying cancer-related fatigue in Asian breast cancer patients.

Reasons Behind Kinesiophobia Among Patients with Malignant Tumors Using VAPs

SOCIODEMOGRAPHIC FACTORS:

Sociodemographic factors, such as gender, literacy, and family income status, have a greater influence on kinesiophobia among patients with malignant tumors who use VAPs [6]. Studying kinesiophobia among older citizens in China [20] uncovered that gender, education level, marital status, and monthly income of family members are significantly correlated with high or low scores of kinesiophobia in elderly people. Patients with higher education levels may have more knowledge about the disease, receive more rational treatment for VAP placement pain, and have lower kinesiophobia scores and a higher incidence of kinesiophobia [31]. Family members also have a significant impact on patients’ motor fear scores. Fang et al [12] studied 24 patients and 53 family members and found that family’s fear of pain was often similar to that of the patients. Family members’ pain and anxiety were significantly higher than that of the patients after witnessing the treatment process. This may aggravate patients’ fear of moving in the later stages. Based on these findings, healthcare professionals not only need to increase the scientific knowledge of patients about their tumors but also should more effectively communicate with the patient’s family members to alleviate patient’s anxiety and fear of pain and movement.

PAIN AND FOREIGN BODY SENSATION:

Related studies have shown that kinesiophobia is also related to the intensity of pain [17], and pain sensation during surgery or after infection is an important factor that causes VAP patients to misjudge movement or even suffer from kinesiophobia. Wang et al studied [4] 282 Chinese patients with tumors who used VAP. It was found that local pain sensation and foreign body sensation after VAP placement were positively correlated with patients’ fear of movement. The pain sensation induces psychological anxiety and fear. Foreign body sensation after VAP placement affects the psychology of patients and aggravates patients’ fear of movement. Compared with other modalities, VAP can reduce the incidence of infection, phlebitis, and other complications, is easy to move about with, and has a longer maintenance cycle. These advantages can improve the quality of life of patients [32], but VAP cannot completely prevent complications. Wang et al [33] recruited 1391 patients with malignant tumors using VAP. They found that infection remains a relatively challenging problem in the treatment of cancer patients using VAP. Based on these findings, the aseptic operation should be strictly considered during VAP placement. Postoperative nursing training should be improved to help healthcare personnel cope with complications such as infections, which may reduce the degree of pain and provide timely counselling to patients to reduce the fear of movement.

CANCER FATIGUE:

Cancer fatigue is also known as cancer-related fatigue (CRF). It is a common symptom among cancer patients brought about by the tumor itself or the treatment. It greatly impacts the quality of life of patients [34]. Liu et al [35] analyzed data from 224 patients who underwent chemotherapy and experienced cancer-related pain. Patients with moderate and severe pain had more symptoms of cancer fatigue compared with patients with mild pain. There was a strong negative correlation between cancer fatigue and the quality of life of patients with moderate and severe pain. Among patients with tumors, cancer fatigue affects the recovery of their physical functions and decreases their quality of life. Moreover, severe cancer fatigue increases kinesiophobia scores and aggravates kinesiophobia in tumor patients [36]. This may be because pain perceived by cancer patients is correlated with the degree of cancer fatigue, which is an important factor affecting kinesiophobia. Meneses-Echa’vez et al [37] showed that supervised exercise can reduce cancer fatigue. To reduce the degree of cancer fatigue and alleviate the fear of exercise in patients with tumors, nursing staff should increasingly pay attention to patients with severe pain after VAP placement. Patients also should exercise more frequently to reduce the impact of cancer fatigue and increase their confidence in subsequent treatments.

PROPOSED MEASURES FOR PATIENTS WITH KINESIOPHOBIA:

Measures should target different psychological statuses and behaviors of cancer patients using VAP, induce a positive attitude towards the disease and pain, and lower the scores of kinesiophobia. Cancer patients with more severe fear and anxiety are more likely to avoid coping with the disease and experience more serious kinesiophobia. Among 258 oncology patients with PICC cannulation, Ting et al [36] found that differences in psychological perceptions of oncology patients, self-regulation abilities and coping styles can affect kinesiophobia scores. Similarly, Yang et al [38] showed that how patients regard the disease, self-confidence, and support from the community alleviated anxiety and fear in cancer patients. After the placement of VAP, healthcare professionals need to understand the psychological status of patients. They should also pay attention to the psychological problems of patients and their behavioral changes in a timely manner and give patients scientific and positive psychological guidance. It is necessary to expand the knowledge about VAP and the diseases to improve the patients’ understanding of VAP. Patients need guidance to positively face physical and psychological changes after VAP implantation.

Strategies for Reducing Kinesiophobia Among Patients with Malignant Tumors Using VAPs

DIGITAL SCIENCE AND DIGITAL THERAPIES:

With the development of digital technology, the use of artificial intelligence and big data is rapidly expanding. The use of digital science and technology in the field of health care is expected to reduce the incidence of kinesiophobia among patients with malignant tumors using VAPs. In a study by Yan et al [39], the effectiveness of a machine learning model in predicting the postoperative pain of 320 patients was measured. The machine learning model had good differentiation ability in identifying patients’ pain. Due to the strong correlation between the degree of fear of movement and the degree of pain among oncology patients, it is expected that in the future, the degree of fear of movement in patients with malignant tumors can be predicted more accurately by numerical techniques after VAP placement. Therefore, healthcare professionals can easily minimize the incidence of kinesiophobia among patients with malignant tumors using VAPs. Papachristou et al [40] showed that healthcare staff should fully understand the concepts of digital technologies to bring the benefit of these digital tools into full play. It is also necessary to take advantage of the clinical experience of nurses to provide patients with more personalized and effective treatment plans for the management of kinesiophobia in oncology patients with VAP.

DIVERSIFIED HEALTH EDUCATION AND EXERCISE THERAPY:

Diversified health education is different from traditional offline health education, using online and offline methods to provide relevant health education for patients and their families. This can deepen the understanding of patients and their families of the relevant diseases and exercise. It can also help patients treat the disease and the subsequent pain. It can also help them understand the exercises needed. Liu et al [41] indicated that the use of diversified health education can enhance the ability of patients with malignant tumors to take care of themselves, and it reduced the incidence of post-chemotherapy complications among patients with malignant tumors using VAPs. The patients were less likely to catastrophize the pain and fear of movement. For treating kinesiophobia, several interventions can help change patients’ ideas about kinesiophobia. Exercise therapy can also be performed. Gutiérrez-Sánchez et al [42] demonstrated the effectiveness of exercise and educational interventions in reducing patients’ fear of movement by studying 82 patients with malignant tumors. Appropriate exercise can also promote the recovery of patients’ physical function by preventing pain catastrophizing and kinesiophobia [43]. Improved physical condition can reduce kinesiophobia. Diversified health education combined with exercise therapy can improve kinesiophobia among patients with malignant tumors using VAPs. They are performed via targeted measures to transmit positive ideas to patients and improve patients’ physical condition.

TRADITIONAL CHINESE CULTURE AND SOCIAL SUPPORT:

Some forms of traditional culture, such as tai chi and taijiquan, might be beneficial to the recovery of physical health and alleviate patients’ kinesiophobia. They are of great historical and cultural value. Hui et al [44] confirmed that taijiquan has positive effects on aerobic fitness, body state, and self-perception. Tai chi can reduce the physical discomfort of patients with malignant tumors using VAPs, and can help cancer patients by reducing physical fatigue. The meta-analysis conducted by Huang et al [45] demonstrated the positive effects of tai chi on the treatment of patients with breast cancer. Tai chi improved the physical functioning and psychological health of cancer patients. Taijiquan is usually performed as a group exercise in China. It has a similar group effect as square dancing and is more popular among the elderly. The authors believe that group exercise can be organized to provide more psychosocial support to patients with malignant tumors using VAPs. Thus, it can help reduce their anxiety and fear after VAP placement. It can also help restore patients’ bodily functions and alleviate patients’ kinesiophobia.

Conclusions

More studies on kinesiophobia are needed in China. There are approximately 33 articles examining kinesiophobia in oncology patients, of which 4 were specifically conducted on patients with malignant tumors using VAPs or PICCs [2,4,5,36]. The relevant preventive and therapeutic experiences on kinesiophobia in tumor patients with VAP still need improvement. Nursing staff can use assessment tools such as the Tampa Rating Scale for Kinesiophobia, the Fear Avoidance Beliefs Questionnaire, and the Cancer Fatigue Scale to reasonably and effectively assess kinesiophobia among patients with malignant tumors who use VAPs. Attention should be paid to the mechanisms and roles of demographic factors, pain and foreign body sensation, cancer fatigue, pain management strategies, and other factors influencing kinesiophobia. Thus, these patients can overcome the fear of movement and achieve a better physical condition. In the future, healthcare professionals need to pay more attention to the role of psychosocial factors in the development of kinesiophobia. The integration of modern science and technology and Chinese traditional culture can improve the treatment and prevention of kinesiophobia among patients with malignant tumors using VAPs.