Kinesiophobia, Physical Activity, and Physical-Activity Self-Efficacy in Pediatric Heart Disease

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Black, Emily Cramer, Lindsey Malloy-Walton, Mollie Walton, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8322413/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Feb, 2026 Read the published version in Pediatric Cardiology → Version 1 posted 9 You are reading this latest preprint version Abstract Background Kinesiophobia—an excessive, often debilitating fear of movement or exercise—has emerged as an important moderator of physical activity (PA) and has been linked with quality of life (QoL), anxiety, and depression in adolescents with heart disease (HD). This study explores additional factors that may be related to cardiac-focused kinesiophobia, including self-efficacy, PA engagement, and QoL. Methods Sixty-three adolescents (mean age = 15.5 years; 49% female) with congenital or acquired HD completed the TSK-Heart-A, the Physical Activity Questionnaire for Adolescents (PAQ-A), the Pediatric Quality of Life Inventory (PedsQL™) Generic Core and Cardiac Module, and the Domain-Specific Physical Activity Efficacy Questionnaire (DSPAEQ-A). Data were analyzed using Kendall’s Tau correlations and bootstrapped partial correlations controlling for PA. Results Greater kinesiophobia correlated with lower PA across both PA measures (τ = −.248), lower PA self-efficacy across household, leisure-time, and ambulatory domains (τ = −.293 to − .356), and poorer QoL for both generic and cardiac scales (τ = −.403, − .400). When controlling for PA, kinesiophobia remained significantly related to lower self-efficacy (r = − .314 to − .368) and poorer QoL (r = − .558, − .520) Discussion Cardiac-focused kinesiophobia is a salient psychological factor in pediatric HD. It is tied to lower PA and poorer QoL and is independently associated with reduced PA self-efficacy—a modifiable resilience construct. These findings support the development of interventions that target fear-avoidance mechanisms and build self-efficacy to improve everyday activity and psychosocial functioning in adolescent HD. Pediatric Heart Disease Kinesiophobia Physical Activity Self-Efficacy Figures Figure 1 Introduction Children and adolescents with congenital and other types of heart disease (HD) engage in significantly less physical activity (PA) than their peers without HD[ 48 ], increasing the likelihood of adopting a persistently inactive lifestyle during adolescence and into adulthood[6; 9; 21–23; 25; 33; 40]. Long-term inactivity is linked to elevated cardiometabolic risk—hypertension, type 2 diabetes, obesity—and premature vascular aging[2; 15; 16]. Compounding physical risk, low PA is associated with worse mental health (higher anxiety and depressive symptoms) and lower quality of life (QoL) in youth[7; 31; 50]. Adolescents with HD are already at increased risk for anxiety and depression due to the lifelong nature of their diagnosis, recurrent medical surveillance, and intermittent restrictions; reduced PA may exacerbate these psychosocial burdens[14; 18; 20; 42]. Children and adolescents with HD are encouraged to be vigilant of their symptoms, which may contribute to physical inactivity. Adolescents are often instructed to monitor for palpitations, chest discomfort, breathlessness, or undue fatigue during exertion and to stop activity or seek care when these sensations occur[38; 39]. While medically prudent, this stance can amplify hypervigilance to bodily sensations and inadvertently cue avoidance of activities perceived as risky—even when such activities are safe and beneficial. These patterns are well described in the fear-avoidance model (FAM) of chronic pain, which posits that catastrophic interpretations of bodily sensations lead to fear, avoidance, deconditioning, and disability[29; 30; 45]. Kori and colleagues applied the fear-avoidance model to PA and termed it ‘kinesiophobia’ (KP), and defined it as an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury[ 26 ]. In adult cardiovascular settings, adaptations of the FAM show that cardiac-related KP can persist well after acute events and is associated with poorer recovery and functioning[4; 24]. In cardiovascular disease, the FAM (see Fig. 1) can be applied to demonstrate how cardiac-related KP may drive hypervigilance and avoidance of PA. We extended this line of work by adapting and validating a pediatric, cardiac-focused measure—the TSK-Heart-A—which showed robust reliability and coherent associations with lower PA and worse psychological functioning and overall QOL in adolescents with HD[ 47 ]. Furthermore, in a sample of children and adolescents with HD, PA was associated with psychological functioning, including anxiety, depression, general QoL, and cardiac specific QoL, consistent with previous studies conducted in adults[3; 4]. Several important gaps remain in this line of research. Prior analyses focused primarily on global QoL and did not test whether KP differentially relates to specific domains (e.g., school, social functioning). Moreover, much of the pediatric KP literature emphasizes risk factors, whereas a complementary resilience perspective suggests that self-efficacy—beliefs about one’s capacity to perform goal-directed- activity—may buffer fear and support engagement[10; 11; 49]. Greater PA self-efficacy has been consistently linked with greater PA engagement and better functional outcomes in pediatric pain and chronic disease[10–12; 19; 35]; however, it has not been examined alongside cardiac-focused KP in adolescents with HD. Study Purpose. In this study, we evaluated whether KP was associated with PA self-efficacy, PA engagement, and QoL in adolescents with HD. We hypothesized that greater KP would be associated with lower self-efficacy, lower PA engagement, and poorer QoL; and these associations—particularly with self-efficacy and QoL—would persist after accounting for PA. Methods Adolescents with HD were recruited from pediatric cardiology clinics at a mid-western tertiary care children’s hospital (Children’s Mercy Kansas City). Participants were recruited with equal allocation by sex. To be included, patients needed to meet the following criteria: 1) adolescents between the ages of 12–18 years; 2) able to complete study measures electronically via REDCap, and 3) diagnosed with one of several HD conditions listed in Table 1 . Patients were excluded if they were non-English speaking, presented with an intellectual or developmental disability precluding their ability to complete surveys independently, had a cardiac surgery or procedure within the past 1-month, had a curative cardiac electrophysiology procedure associated with their primary cardiac diagnosis, or lacked a parent or legally authorized representative (LAR) who was able to provide consent. Table 1 – Participant Demographics and Health History Frequency (%) or Mean (SD) Race (%) White 50 (80.7) Black 6 (9.7) Multiracial 3 (4.8) Hispanic 2 (3.2) Native American 1 (1.6) Ethnicity (%) Non-Hispanic/Latinx 59 (93.7) Hispanic/Latinx 4 (6.4) Age at assessment (y) 15.46 (1.82) BMI z-score 0.67 (1.14) Age at diagnosis (y) 6.26 (6.19) Cardiac clinic appointments (past year) 2.67 (2.86) Cardiac clinic appointments (past 5 years) 7.70 (6.77) Emergency department visits (lifetime) 4.79 (8.14) Cardiac Diagnosis (%) Single ventricle 19 (30.2) Cardiomyopathy 12 (19.1) Long QT syndrome 10 (15.9) Complex SVT 7 (11.1) WPW 7 (11.1) ARVC 3 (4.8) Ventricular tachycardia 3 (4.8) CPVT 1 (1.6) Unexplained cardiac arrest 1 (1.6) Presence of secondary cardiac diagnosis (%) Yes 19 (30.2) No 44 (69.8) Taking cardiac medications (%) Yes 39 (61.9) No 24 (38.1) History of invasive cardiac procedures (lifetime) (%) Yes 39 (61.9) No 24 (38.1) Implanted cardiac device (%) Yes 12 (19.7) No 49 (80.3) Immediate family history of cardiac disease (%) Yes 25 (39.7) No 38 (60.3) Note. Values are presented as frequency (%) or mean (standard deviation). Abbreviations: ARVC = arrhythmogenic right ventricular cardiomyopathy; BMI = body mass index; CPVT = catecholaminergic polymorphic ventricular tachycardia; SVT = supraventricular tachycardia; WPW = Wolff–Parkinson–White. Data adapted from Olson et al. (2025). The study was approved by the Children’s Mercy Kansas City IRB. Adolescents and their parents or LAR provided assent and consent to participate in the study, respectively. All study procedures were in accordance with the Children’s Mercy Kansas City institutional research guidelines and the ethical standards of the 1964 Helsinki Declaration and its later amendments. Measures Tampa Scale of Kinesiophobia – Heart- Adolescent version (TSK-Heart-A). The TSK-Heart-A consisted of 17 Likert-scale items (score of 1 – strongly disagree; score of 4 – strongly agree)[ 32 ], with a total score ranging from 17 (low KP) to 68 (high KP). The TSK-Heart-A assesses the extent to which individuals report fear of injury associated with PA or exercise, their avoidance of exercise, the extent to which they feel that PA is dangerous for their heart condition, and their sense of dysfunction[ 4 ]. Our formative research demonstrated that the TSK-Heart-A has good internal and test-retest reliability and construct validity[ 47 ]. Physical Activity. PA over the previous 7-days was estimated using the self-report Physical Activity Questionnaire for Adolescents (PAQ-A)[27; 28]. Voss and colleagues established that the PAQ-A is reliable and valid in youth with HD, with the summary scores correlating with total PA assessed with a waist-worn ActiGraph device ( r = 0.52)[ 46 ]. The 8-item PAQ-A is designed to assess participation in both recreational and school-based PA. The PAQ-A summary score is an average of each survey items ranging from 1 to 5 (lowest to highest PA, respectively). Quality of Life. Pediatric Quality of Life Inventory (PedsQL™) Generic Core Scale v4.0. The PedsQL™ Generic Core Scale consists of 23-items, scored on a 5-response scale (“Never” to “Almost always”), and subdivided into four subscales: physical (8-items), emotional (5-items), school (5-items), and social functioning (5-items). Descriptive responses aligned with numeric values and were reverse scored and summed to elucidate an overall summary score and subscale scores as described in the scoring manual with a range from 0 to 100 (lowest to highest QoL, respectively)[ 43 ]. Pediatric Quality of Life Inventory (PedsQL™) Cardiac Module v3.0[41; 44]. The PedsQL™ Cardiac Module consists of 22-items, subdivided into six subscales: heart problems and treatment (7-items), treatment (heart medications (5-items), perceived physical appearance (3-items), treatment anxiety (4-items), cognitive problems (5-items), and communication (3-items). Domain-Specific Physical Activity Efficacy Questionnaire – Adolescent Version (DSPAEQ-A). The DSPAEQ-A assessed the confidence of adolescents in their ability to perform PA across different domains. For this study, domains of functioning assessed included household PA (5-items), such as household chores performed at a light or moderate intensity; leisure and recreation PA (6-items), such as sports or gym time; and ambulatory school and transportation PA (6-items), including walking to and at school, and other specific places, such as work or home. Participants indicate how confident they are that they can perform PA across different time-lengths (i.e., 15-minutes, 30 minutes), intensity levels (i.e., light, moderate, vigorous), and frequencies (i.e., two or more days a week, every day). Confidence is rated on an 11-point scale, in 10% increments (0%, 11%... 90%, 100% confident). Statistical Analyses Statistical analysis was completed in SPSS v. 28.0.0. Categorical variables (i.e., gender and ethnicity) are presented as frequencies, and continuous variables are presented as mean and standard deviations. Continuous variables were evaluated for skew and kurtosis, with Z = ± 2 as the criterion. Several subscales were elevated for skew, kurtosis, or both, including the PedsQL and PedsQL Cardiac subscales, the PAQ summative score, and both the household activities and ambulatory activity subscales of the DSPAEQ-A. To account for non-normality, Kendall’s Tau correlations were conducted between TSK-Heart-A score, PAQ-A score, and the PedsQL scales, with a statistical significance of α = .05. Exploratory Analyses. Partial correlations with bootstrapping, performed at 1000 samples, were also conducted to evaluate the independent relationships between the TSK-Heart-A, PA self-efficacy, and QOL, while controlling for PA. Results Participants Sixty-three adolescents (Mage = 15.5, SD = 1.8) enrolled in the study and completed all measures. Participant demographics are included in Table 1 and have been reported elsewhere[34; 47]. Participants were primarily White (n = 50, 81%) and non-Hispanic (n = 59, 93.7%). The sample includes a similar number of biological females (n = 31, 49.2) to males. The most common diagnoses included single ventricle (n = 19, 30.2%), cardiomyopathy (n = 12, 19.1%), and long QT syndrome (n = 10, 15.9%). As reported previously[ 47 ], these participants demonstrated a moderate degree of KP. Scores for all measures and sub-scales are provided in Table 2 . Table 2 – Descriptive Statistics for Self-Report Measures N Mean Median SD 95% CI TSK 63 35.44 35.00 8.04 33.47, 38.11 PAQ 62 1.95 1.82 0.65 1.76, 2.15 PEDSQL Phys. 63 75.15 78.13 20.29 68.19, 80.91 PEDSQL Emot. 63 74.68 80.00 25.21 69.40, 84.41 PEDSQL Soc. 63 82.06 85.00 18.87 75.51, 87.35 PEDSQL School 63 68.73 75.00 25.38 63.60, 78.78 PEDSQL Total 63 75.16 78.26 18.87 70.14, 81.52 CARDQL Heart Prob. 63 69.61 71.43 20.57 64.41, 76.41 CARDQL Meds 43 91.63 95.00 9.98 88.65, 94.92 CARDQL Phys. Appearance 63 81.35 91.67 22.98 77.90, 90.35 CARDQL Treat. Anx. 63 77.38 87.50 27.16 73.01, 87.41 CARDQL Cog. Probs. 63 64.84 65.00 26.97 60.33, 75.63 CARDQL Comm. 63 76.19 83.33 23.28 74.39, 86.72 CARDQL Total 63 74.66 75.93 17.49 74.05, 81.99 DSPAEQ House 62 83.25 92.50 20.64 74.19, 89.42 DSPAEQ Leisure 62 63.65 64.67 28.31 54.13, 70.96 DSPAEQ Ambulatory /Transport 62 84.49 95.92 22.57 74.53, 90.12 TSK-HEART-A, PA, and PA Self-Efficacy Greater heart-symptom focused KP, as reported previously[ 47 ], was associated with lower self-reported PA by adolescents ( τ = − .248, p = .005). Greater KP was also negatively associated with self-efficacy for PA completed around the household ( τ = − .293, p = .001), PA during leisure-time ( τ = − .327, p < .001), and ambulatory and transportation PA ( τ = − .356, p < .001). Additionally, higher levels of PA were associated with higher PA efficacy across all domains (Table 3 ). Independent Relationships: TSK-HEART-A and PA Self-Efficacy. KP was negatively correlated with all three domains of PA self-efficacy ( τ = − .293 to − .356, p < .01). To evaluate the unique relationship between KP and PA self-efficacy, partial correlations with bootstrapping were conducted to while controlling for self-reported PA from the PAQ-A. Results showed that higher KP was significantly related to less PA self-efficacy in all three domains (r = − .314 to − .368, p < .015), while controlling for physical activity level. TSK-HEART-A, PEDS-QL, PEDS-QL Cardiac As previously reported, greater heart-symptom focused KP was significantly associated with poorer general QoL ( τ = − .403, p < .001), and cardiac focused QoL ( τ = − .400, p < .001). Across the generic subscales, higher KP was significantly associated with poorer QoL across all domains but was expectedly most related to physical functioning ( τ = − .444, p < .001). KP was also generally associated with cardiac focused QoL, across multiple domains, including QoL related to physical appearance, cognitive problems, and communication difficulties (p < .05); TSK-Heart-A was also most notably related to heart-problem related QoL ( τ = − .457, p < .001). Independent Relationships: TSK-HEART-A and QoL : Partial correlations with bootstrapping were conducted to evaluate the relationship between KP and QoL while controlling for self-reported PA from the PAQ-A. Results showed that higher KP was significantly associated with poorer overall QoL (r = − .558, p < .001) and cardiac QoL (r = − .520, p < .001). PA and QoL As reported elsewhere[ 34 ], higher self-reported PA from the PAQ was associated with better generic QoL ( τ = .270, p = .002), physical function ( τ = .265, p = .003), and emotional functioning ( τ = .233, p < .05). The PAQ was also significantly related cardiac specific QoL overall ( τ = .260, p = .003) and in the domains heart problems ( τ = .220, p = .013), physical appearance ( τ = .241, p = .011), and cognitive problems ( τ = .271, p = .002). Discussion Adolescents with HD can become overly cautious and may self-restrict even moderate intensity PA out of fear of provoking an arrhythmia or “damaging their heart.” These fears are often learned and reinforced through explicit messages from clinicians and parents (e.g., strong symptom monitoring instructions) and through implicit learning when benign exertional sensations (e.g., palpitations, breathlessness) are interpreted as dangerous. Over time, this combination fosters hypervigilance, consolidates fear-avoidance behaviors, and drives progressive disengagement from PA, ultimately entrenching a sedentary lifestyle. To examine this mechanism quantitatively, we used the recently developed and validated TSK-Heart-A[ 47 ], a cardiac specific KP measure for adolescents with HD, to test relationships among HD-specific KP, PA, QoL, and PA self-efficacy. Incorporating this measure enables clinical research to isolate cardiac focused contributors to movement related- fear that generic anxiety or distress scales may miss, thereby clarifying actionable treatment targets. Prior work in this cohort has shown that higher PA relates to better QoL and fewer anxiety/depressive symptoms[ 34 ]; the present study extends those findings by jointly evaluating KP and PA self-efficacy—two complementary, theoretically linked constructs that shape day-to- day PA engagement in pediatric HD. Quality of life findings. As anticipated, higher scores on the TSK-Heart-A were associated with poorer QoL on both the generic and cardiac specific PedsQL™ measures, and these associations were most pronounced for patient reported physical functioning and heart problem domains. This pattern is conceptually coherent with the measure’s design history: in adapting the TSK for adolescents with HD, we deliberately emphasized heart related threat appraisals, activity linked danger beliefs, and avoidance of exertion in the item set to capture fear processes that are salient during everyday activity in this population. It follows that a scale organized around cardiac vulnerability during movement would correlate most strongly with domains that index physical capability and cardiac symptom burden. At the same time, it is important to underscore that TSK-Heart-A scores were also significantly related to all other QoL domains (including emotional, social, and school functioning). This broader pattern supports the view that KP is not merely a narrow exercise concern; rather, it reflects a more pervasive threat avoidance stance that can diffuse across daily roles, mood, peer engagement, and academic participation. Taken together, these results provide additional validation support for the TSK-Heart-A, suggesting the instrument aligns closely with physically and physiologically anchored aspects of functioning, as expected from its content focus; yet it also tracks general functional vulnerability that extends beyond the gym or sports field. Practically, this suggests the TSK-Heart-A may be useful both as a domain specific index of heart focused fear and as a proxy signal for broader PA-related functional impairment that clinicians should consider when planning counseling, clearance, or rehabilitation. Self-efficacy findings and implications. We also observed a robust association between TSK-Heart-A scores and PA self-efficacy, and—critically—that this relationship persisted after controlling for PA. The persistence of this effect indicates- that the link between fear and efficacy is not reducible to whether adolescents are already active; it reflects how youth think about, interpret, and anticipate their capacity to be active in the context of HD. In other words, KP may undermine confidence in PA engagement—dampening willingness to initiate or persist in PA even when current behavior levels are held constant. Conceptually, this positions self-efficacy as a resilience factor that can buffer the impact of fear and catastrophic appraisals on daily functioning[ 19 ]. Accordingly, intervention designs should not focus solely on reducing risk factors (e.g., fear, avoidance) but should also build strengths that facilitate action (e.g., graded mastery experiences, supportive performance feedback from clinicians and exercise professionals, peer modeling and group-based PA, and skills for reinterpreting benign exertional sensations). In concert with our findings linking KP to multiple QoL domains, targeting PA self-efficacy- is a potential treatment target for increasing day-to-day activity in pediatric HD. Within the broader literature, additional resilience-oriented constructs—such as positive affect, intrinsic and autonomous motivation, and acceptance- -based responding to internal sensations[5; 12; 13; 37]—also show promise as complementary targets. While global resilience has been associated with better exercise participation, mental health, and even lower healthcare utilization in pediatric HD[ 17 ], it remains unclear which specific components most directly support PA engagement in this population. The present finding—that KP relates to self-efficacy independently of PA—further suggests that effective PA programming will likely require more than prescribing additional exercise bouts. Programs may need to include structured cognitive behavioral- elements (e.g., graded exposure to exertion cues, cognitive reappraisal of interoceptive signals)[ 8 ], motivational strategies (e.g., goal setting with autonomy support), and family-inclusive coaching, so that adolescents not only do more PA but also feel more capable and safer doing it—and can sustain those behaviors over time. Limitations and Future Direction . Despite the strength of using a cardiac specific- measure of KP tailored for adolescents with HD, several limitations warrant consideration and point to clear next steps. First, although the TSK-Heart-A total score has been validated, the putative subscales (e.g., fear of injury , avoidance of exercise , perceived danger for heart problems , and dysfunctional self ) have not yet been psychometrically confirmed in adolescents.[3; 4]. Future work should formally evaluate these subdomains—through factor analytic methods, reliability testing, and measurement invariance across age, sex, and diagnostic groups—and determine clinically meaningful cut scores and responsiveness to change. Establishing valid subscales could clarify which fear related- processes matter most for which patients, directly informing targeted intervention components and clinical decision making. Second, this study relied on self-reported PA, which can introduce shared method- variance with other self-report outcomes (e.g., QoL) and potentially inflate associations. To reduce mono-method bias and improve precision, future studies should incorporate objective PA monitoring (e.g., accelerometry or activPAL) alongside validated self-report tools and harmonize analytic approaches to integrate device based- and perceived PA data. Third, the current sample was not powered to test more complex mechanistic models implied by the fear-avoidance framework (e.g., whether KP undermines PA self-efficacy, which then limits PA and, in turn, lowers QoL)[13; 45]. Larger, multisite and ideally longitudinal studies are needed to evaluate mediational pathways and directional effects, and to examine potential moderators (e.g., diagnosis category, treatment history) that could identify subgroups most likely to benefit from specific intervention strategies. Finally, we did not assess parent/caregiver factors. Given evidence that caregiver beliefs, anxiety, and protective behaviors shape youths’ appraisals and behaviors, KP may be partly an interpersonal process in pediatric HD[1; 36]. Future research should include parent–child dyads, assess caregiver KP and PA beliefs, and test family based- mechanisms of change. Addressing these limitations—subscale validation, objective PA measurement, adequately powered mechanistic designs, and dyadic perspectives—will sharpen construct fidelity and elucidate actionable treatment targets for next generation- interventions that integrate CBT/exposure, exercise training, and family education. Conclusion Cardiac focused KP is a clinically meaningful construct that may help explain why many adolescents with HD under engage in PA and report lower QoL. Beyond its association with PA behavior, KP is independently related to lower PA self-efficacy and poorer QoL, highlighting the need to co target fear avoidance processes and efficacy building within pediatric cardiac rehabilitation and lifestyle counseling. This integrative, resilience-oriented approach has potential to improve psychosocial wellbeing and everyday functioning while supporting safe, lifelong activity in youth with HD. Declarations Author Contribution Statement: All authors contributed to the origination and review of this manuscript. WRB and DAW led the initial conceptualization of the project. Data analyses were completed by WRB and EC. Competing Interest and Disclosures: The authors have no competing interest or disclosures to report. Data availability: Data will be available in aggregate upon request. References Asmundson GJ, Noel M, Petter M, Parkerson HA (2012) Pediatric fear-avoidance model of chronic pain: foundation, application and future directions. 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Clin J Pain 7(1):51 Okasha M, McCarron P, Gunnell D, Davey Smith G (2003) Exposures in childhood, adolescence and early adulthood and breast cancer risk: a systematic review of the literature. Breast Cancer Res Treat 78(2):223–276 Olson OJ, Garver M, Cramer E, Gross-Toalson J, Teson KM, Malloy-Walton L, Watson JS, Walton MM, Martis LB, Watkins DJ, Enneking B, Black WR, White DA Physical Activity and Mental Health in Adolescents With Cardiac Arrhythmias, Cardiomyopathy, or Single Ventricle Heart Disease. Pediatr Exerc Sci 2025:1–9. 10.1123/pes.2024-0066 Parsons RD, McParland JL, Halligan SL, Goubert L, Jordan A (2024) The perception, understanding and experience of flourishing in young people living with chronic pain: A Q-methodology study. J Health Psychol 29(12):1350–1364. 10.1177/13591053241237341 Simons LE, Smith A, Kaczynski K, Basch M (2015) Living in fear of your child's pain: the Parent Fear of Pain Questionnaire. 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Eur J Prev Cardiol 19(5):1034–1065 Telama R, Yang X, Laakso L, Viikari J (1997) Physical activity in childhood and adolescence as predictor of physical activity in young adulthood. Am J Prev Med 13(4):317–323 Uzark K, Jones K, Burwinkle TM, Varni JW (2003) The Pediatric Quality of Life Inventory™ in children with heart disease. Prog Pediatr Cardiol 18(2):141–149 Uzark K, Jones K, Slusher J, Limbers CA, Burwinkle TM, Varni JW (2008) Quality of life in children with heart disease as perceived by children and parents. Pediatrics 121(5):e1060–e1067 Varni JW (2023) Scaling and scoring for the acute and standard versions of the Pediatric Quality of Life Inventory. In: JW Varni editor Varni JW, Burwinkle TM, Seid M, Skarr D (2003) The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity. Ambul Pediatr 3(6):329–341 Vlaeyen JW, Linton SJ (2000) Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85(3):317–332 Voss C, Dean PH, Gardner RF, Duncombe SL, Harris KC (2017) Validity and reliability of the physical activity questionnaire for Children (PAQ-C) and adolescents (PAQ-A) in individuals with congenital heart disease. PLoS ONE ;12(4) White DA, Black WR, Cramer E, Malloy-Walton L, Walton M, Martis L, Enneking B, Teson KM, Watson JS, Gross-Toalson J (2025) Validity and Reliability of the Tampa Scale for Kinesiophobia for Adolescents with Heart Disease. Med Sci Sports Exerc 57(6):1246–1256. 10.1249/MSS.0000000000003642 White DA, Willis EA, Panchangam C, Teson KM, Watson JS, Birnbaum BF, Shirali G, Parthiban A (2020) Physical Activity Patterns in Children and Adolescents With Heart Disease. Pediatr Exerc Sci 1(aop):1–8 Woby SR, Urmston M, Watson PJ (2007) Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients. Eur J Pain 11(7):711–718. 10.1016/j.ejpain.2006.10.009 Wu XY, Han LH, Zhang JH, Luo S, Hu JW, Sun K (2017) The influence of physical activity, sedentary behavior on health-related quality of life among the general population of children and adolescents: A systematic review. PLoS ONE 12(11):e0187668 Table 3 Table 3 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table3.docx Cite Share Download PDF Status: Published Journal Publication published 12 Feb, 2026 Read the published version in Pediatric Cardiology → Version 1 posted Editorial decision: Revision requested 10 Jan, 2026 Reviews received at journal 07 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviews received at journal 29 Dec, 2025 Reviewers agreed at journal 17 Dec, 2025 Reviewers invited by journal 15 Dec, 2025 Editor assigned by journal 10 Dec, 2025 Submission checks completed at journal 10 Dec, 2025 First submitted to journal 09 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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12:31:23","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":150299,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8322413/v1/e49fb4ca7283a284ac57d9e7.html"},{"id":98757047,"identity":"6f1280de-7e8a-445f-b7fb-80a8a0bc1fc8","added_by":"auto","created_at":"2025-12-22 09:36:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4493,"visible":true,"origin":"","legend":"\u003cp\u003eIn cardiovascular disease, the FAM can be applied to demonstrate how cardiac-related KP may drive hypervigilance and avoidance of PA.\u003c/p\u003e","description":"","filename":"fig.png","url":"https://assets-eu.researchsquare.com/files/rs-8322413/v1/ecbf3562338f34407b8d62e5.png"},{"id":102786733,"identity":"32ac9171-e383-4480-b9c8-df311ce27cb7","added_by":"auto","created_at":"2026-02-16 16:15:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":776474,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8322413/v1/7855378a-07fc-46e2-b301-344c71f1b449.pdf"},{"id":98757044,"identity":"fb6f689c-95f2-4e26-a8be-c444f39aa7f5","added_by":"auto","created_at":"2025-12-22 09:36:27","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":42785,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8322413/v1/6e767566a131a5d26c7f6a48.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Kinesiophobia, Physical Activity, and Physical-Activity Self-Efficacy in Pediatric Heart Disease","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChildren and adolescents with congenital and other types of heart disease (HD) engage in significantly less physical activity (PA) than their peers without HD[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], increasing the likelihood of adopting a persistently inactive lifestyle during adolescence and into adulthood[6; 9; 21\u0026ndash;23; 25; 33; 40]. Long-term inactivity is linked to elevated cardiometabolic risk\u0026mdash;hypertension, type 2 diabetes, obesity\u0026mdash;and premature vascular aging[2; 15; 16]. Compounding physical risk, low PA is associated with worse mental health (higher anxiety and depressive symptoms) and lower quality of life (QoL) in youth[7; 31; 50]. Adolescents with HD are already at increased risk for anxiety and depression due to the lifelong nature of their diagnosis, recurrent medical surveillance, and intermittent restrictions; reduced PA may exacerbate these psychosocial burdens[14; 18; 20; 42].\u003c/p\u003e \u003cp\u003eChildren and adolescents with HD are encouraged to be vigilant of their symptoms, which may contribute to physical inactivity. Adolescents are often instructed to monitor for palpitations, chest discomfort, breathlessness, or undue fatigue during exertion and to stop activity or seek care when these sensations occur[38; 39]. While medically prudent, this stance can amplify hypervigilance to bodily sensations and inadvertently cue avoidance of activities perceived as risky\u0026mdash;even when such activities are safe and beneficial.\u003c/p\u003e \u003cp\u003eThese patterns are well described in the fear-avoidance model (FAM) of chronic pain, which posits that catastrophic interpretations of bodily sensations lead to fear, avoidance, deconditioning, and disability[29; 30; 45]. Kori and colleagues applied the fear-avoidance model to PA and termed it \u0026lsquo;kinesiophobia\u0026rsquo; (KP), and defined it as an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In adult cardiovascular settings, adaptations of the FAM show that cardiac-related KP can persist well after acute events and is associated with poorer recovery and functioning[4; 24]. In cardiovascular disease, the FAM (see Fig.\u0026nbsp;1) can be applied to demonstrate how cardiac-related KP may drive hypervigilance and avoidance of PA. We extended this line of work by adapting and validating a pediatric, cardiac-focused measure\u0026mdash;the TSK-Heart-A\u0026mdash;which showed robust reliability and coherent associations with lower PA and worse psychological functioning and overall QOL in adolescents with HD[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Furthermore, in a sample of children and adolescents with HD, PA was associated with psychological functioning, including anxiety, depression, general QoL, and cardiac specific QoL, consistent with previous studies conducted in adults[3; 4].\u003c/p\u003e \u003cp\u003eSeveral important gaps remain in this line of research. Prior analyses focused primarily on global QoL and did not test whether KP differentially relates to specific domains (e.g., school, social functioning). Moreover, much of the pediatric KP literature emphasizes risk factors, whereas a complementary resilience perspective suggests that self-efficacy\u0026mdash;beliefs about one\u0026rsquo;s capacity to perform goal-directed- activity\u0026mdash;may buffer fear and support engagement[10; 11; 49]. Greater PA self-efficacy has been consistently linked with greater PA engagement and better functional outcomes in pediatric pain and chronic disease[10\u0026ndash;12; 19; 35]; however, it has not been examined alongside cardiac-focused KP in adolescents with HD.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy Purpose.\u003c/b\u003e In this study, we evaluated whether KP was associated with PA self-efficacy, PA engagement, and QoL in adolescents with HD. We hypothesized that greater KP would be associated with lower self-efficacy, lower PA engagement, and poorer QoL; and these associations\u0026mdash;particularly with self-efficacy and QoL\u0026mdash;would persist after accounting for PA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAdolescents with HD were recruited from pediatric cardiology clinics at a mid-western tertiary care children\u0026rsquo;s hospital (Children\u0026rsquo;s Mercy Kansas City). Participants were recruited with equal allocation by sex. To be included, patients needed to meet the following criteria: 1) adolescents between the ages of 12\u0026ndash;18 years; 2) able to complete study measures electronically via REDCap, and 3) diagnosed with one of several HD conditions listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients were excluded if they were non-English speaking, presented with an intellectual or developmental disability precluding their ability to complete surveys independently, had a cardiac surgery or procedure within the past 1-month, had a curative cardiac electrophysiology procedure associated with their primary cardiac diagnosis, or lacked a parent or legally authorized representative (LAR) who was able to provide consent.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Participant Demographics and Health History\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%) or Mean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRace (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (80.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (9.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiracial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNative American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEthnicity (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Hispanic/Latinx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (93.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHispanic/Latinx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge at assessment (y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.46 (1.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBMI z-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67 (1.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge at diagnosis (y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.26 (6.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCardiac clinic appointments (past year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.67 (2.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCardiac clinic appointments (past 5 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.70 (6.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEmergency department visits (lifetime)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.79 (8.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCardiac Diagnosis (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle ventricle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (30.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardiomyopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (19.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLong QT syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (15.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplex SVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWPW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eARVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVentricular tachycardia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCPVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnexplained cardiac arrest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePresence of secondary cardiac diagnosis (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (30.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (69.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTaking cardiac medications (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (61.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (38.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHistory of invasive cardiac procedures (lifetime) (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (61.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (38.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eImplanted cardiac device (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (19.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (80.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eImmediate family history of cardiac disease (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (39.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (60.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote. Values are presented as frequency (%) or mean (standard deviation). Abbreviations: ARVC\u0026thinsp;=\u0026thinsp;arrhythmogenic right ventricular cardiomyopathy; BMI\u0026thinsp;=\u0026thinsp;body mass index; CPVT\u0026thinsp;=\u0026thinsp;catecholaminergic polymorphic ventricular tachycardia; SVT\u0026thinsp;=\u0026thinsp;supraventricular tachycardia; WPW\u0026thinsp;=\u0026thinsp;Wolff\u0026ndash;Parkinson\u0026ndash;White. Data adapted from Olson et al. (2025).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe study was approved by the Children\u0026rsquo;s Mercy Kansas City IRB. Adolescents and their parents or LAR provided assent and consent to participate in the study, respectively. All study procedures were in accordance with the Children\u0026rsquo;s Mercy Kansas City institutional research guidelines and the ethical standards of the 1964 Helsinki Declaration and its later amendments.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003e \u003cb\u003eTampa Scale of Kinesiophobia \u0026ndash; Heart- Adolescent version (TSK-Heart-A).\u003c/b\u003e The TSK-Heart-A consisted of 17 Likert-scale items (score of 1 \u0026ndash; strongly disagree; score of 4 \u0026ndash; strongly agree)[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], with a total score ranging from 17 (low KP) to 68 (high KP). The TSK-Heart-A assesses the extent to which individuals report fear of injury associated with PA or exercise, their avoidance of exercise, the extent to which they feel that PA is dangerous for their heart condition, and their sense of dysfunction[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Our formative research demonstrated that the TSK-Heart-A has good internal and test-retest reliability and construct validity[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhysical Activity.\u003c/b\u003e PA over the previous 7-days was estimated using the self-report Physical Activity Questionnaire for Adolescents (PAQ-A)[27; 28]. Voss and colleagues established that the PAQ-A is reliable and valid in youth with HD, with the summary scores correlating with total PA assessed with a waist-worn ActiGraph device (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.52)[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The 8-item PAQ-A is designed to assess participation in both recreational and school-based PA. The PAQ-A summary score is an average of each survey items ranging from 1 to 5 (lowest to highest PA, respectively).\u003c/p\u003e \u003cp\u003e \u003cb\u003eQuality of Life.\u003c/b\u003e Pediatric Quality of Life Inventory (PedsQL\u0026trade;) Generic Core Scale v4.0. The PedsQL\u0026trade; Generic Core Scale consists of 23-items, scored on a 5-response scale (\u0026ldquo;Never\u0026rdquo; to \u0026ldquo;Almost always\u0026rdquo;), and subdivided into four subscales: physical (8-items), emotional (5-items), school (5-items), and social functioning (5-items). Descriptive responses aligned with numeric values and were reverse scored and summed to elucidate an overall summary score and subscale scores as described in the scoring manual with a range from 0 to 100 (lowest to highest QoL, respectively)[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePediatric Quality of Life Inventory (PedsQL\u0026trade;) Cardiac Module v3.0[41; 44]. The PedsQL\u0026trade; Cardiac Module consists of 22-items, subdivided into six subscales: heart problems and treatment (7-items), treatment (heart medications (5-items), perceived physical appearance (3-items), treatment anxiety (4-items), cognitive problems (5-items), and communication (3-items).\u003c/p\u003e \u003cp\u003e\u003cb\u003eDomain-Specific Physical Activity Efficacy Questionnaire \u0026ndash; Adolescent Version (DSPAEQ-A).\u003c/b\u003e The DSPAEQ-A assessed the confidence of adolescents in their ability to perform PA across different domains. For this study, domains of functioning assessed included household PA (5-items), such as household chores performed at a light or moderate intensity; leisure and recreation PA (6-items), such as sports or gym time; and ambulatory school and transportation PA (6-items), including walking to and at school, and other specific places, such as work or home. Participants indicate how confident they are that they can perform PA across different time-lengths (i.e., 15-minutes, 30 minutes), intensity levels (i.e., light, moderate, vigorous), and frequencies (i.e., two or more days a week, every day). Confidence is rated on an 11-point scale, in 10% increments (0%, 11%... 90%, 100% confident).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatistical Analyses\u003c/h3\u003e\n\u003cp\u003eStatistical analysis was completed in SPSS v. 28.0.0. Categorical variables (i.e., gender and ethnicity) are presented as frequencies, and continuous variables are presented as mean and standard deviations. Continuous variables were evaluated for skew and kurtosis, with Z\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;2 as the criterion. Several subscales were elevated for skew, kurtosis, or both, including the PedsQL and PedsQL Cardiac subscales, the PAQ summative score, and both the household activities and ambulatory activity subscales of the DSPAEQ-A. To account for non-normality, Kendall\u0026rsquo;s Tau correlations were conducted between TSK-Heart-A score, PAQ-A score, and the PedsQL scales, with a statistical significance of α\u0026thinsp;=\u0026thinsp;.05.\u003c/p\u003e \u003cp\u003e \u003cem\u003eExploratory Analyses.\u003c/em\u003e Partial correlations with bootstrapping, performed at 1000 samples, were also conducted to evaluate the independent relationships between the TSK-Heart-A, PA self-efficacy, and QOL, while controlling for PA.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eSixty-three adolescents (Mage\u0026thinsp;=\u0026thinsp;15.5, SD\u0026thinsp;=\u0026thinsp;1.8) enrolled in the study and completed all measures. Participant demographics are included in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and have been reported elsewhere[34; 47]. Participants were primarily White (n\u0026thinsp;=\u0026thinsp;50, 81%) and non-Hispanic (n\u0026thinsp;=\u0026thinsp;59, 93.7%). The sample includes a similar number of biological females (n\u0026thinsp;=\u0026thinsp;31, 49.2) to males. The most common diagnoses included single ventricle (n\u0026thinsp;=\u0026thinsp;19, 30.2%), cardiomyopathy (n\u0026thinsp;=\u0026thinsp;12, 19.1%), and long QT syndrome (n\u0026thinsp;=\u0026thinsp;10, 15.9%). As reported previously[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], these participants demonstrated a moderate degree of KP. Scores for all measures and sub-scales are provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Descriptive Statistics for Self-Report Measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTSK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e33.47, 38.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePAQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.76, 2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePEDSQL Phys.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68.19, 80.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePEDSQL Emot.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e69.40, 84.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePEDSQL Soc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e75.51, 87.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePEDSQL School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e63.60, 78.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePEDSQL Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e70.14, 81.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCARDQL Heart Prob.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e64.41, 76.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCARDQL Meds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e88.65, 94.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCARDQL Phys. Appearance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e77.90, 90.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCARDQL Treat. Anx.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e73.01, 87.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCARDQL Cog. Probs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e60.33, 75.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCARDQL Comm.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e83.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e74.39, 86.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCARDQL Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e74.05, 81.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDSPAEQ House\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e92.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e74.19, 89.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDSPAEQ Leisure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e54.13, 70.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDSPAEQ Ambulatory /Transport\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e74.53, 90.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTSK-HEART-A, PA, and PA Self-Efficacy\u003c/h3\u003e\n\u003cp\u003eGreater heart-symptom focused KP, as reported previously[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], was associated with lower self-reported PA by adolescents (\u003cem\u003eτ =\u003c/em\u003e \u0026minus;\u0026thinsp;.248, p\u0026thinsp;=\u0026thinsp;.005). Greater KP was also negatively associated with self-efficacy for PA completed around the household (\u003cem\u003eτ =\u003c/em\u003e \u0026minus;\u0026thinsp;.293, p\u0026thinsp;=\u0026thinsp;.001), PA during leisure-time (\u003cem\u003eτ =\u003c/em\u003e \u0026minus;\u0026thinsp;.327, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and ambulatory and transportation PA (\u003cem\u003eτ =\u003c/em\u003e \u0026minus;\u0026thinsp;.356, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Additionally, higher levels of PA were associated with higher PA efficacy across all domains (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003eIndependent Relationships: TSK-HEART-A and PA Self-Efficacy.\u003c/em\u003e KP was negatively correlated with all three domains of PA self-efficacy (\u003cem\u003eτ =\u003c/em\u003e \u0026minus;\u0026thinsp;.293 to \u0026minus;\u0026thinsp;.356, p\u0026thinsp;\u0026lt;\u0026thinsp;.01). To evaluate the unique relationship between KP and PA self-efficacy, partial correlations with bootstrapping were conducted to while controlling for self-reported PA from the PAQ-A. Results showed that higher KP was significantly related to less PA self-efficacy in all three domains (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.314 to \u0026minus;\u0026thinsp;.368, p\u0026thinsp;\u0026lt;\u0026thinsp;.015), while controlling for physical activity level.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTSK-HEART-A, PEDS-QL, PEDS-QL Cardiac\u003c/h2\u003e \u003cp\u003eAs previously reported, greater heart-symptom focused KP was significantly associated with poorer general QoL (\u003cem\u003eτ =\u003c/em\u003e \u0026minus;\u0026thinsp;.403, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and cardiac focused QoL (\u003cem\u003eτ =\u003c/em\u003e \u0026minus;\u0026thinsp;.400, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Across the generic subscales, higher KP was significantly associated with poorer QoL across all domains but was expectedly most related to physical functioning (\u003cem\u003eτ =\u003c/em\u003e \u0026minus;\u0026thinsp;.444, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). KP was also generally associated with cardiac focused QoL, across multiple domains, including QoL related to physical appearance, cognitive problems, and communication difficulties (p\u0026thinsp;\u0026lt;\u0026thinsp;.05); TSK-Heart-A was also most notably related to heart-problem related QoL (\u003cem\u003eτ =\u003c/em\u003e \u0026minus;\u0026thinsp;.457, p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003e \u003cem\u003eIndependent Relationships: TSK-HEART-A and QoL\u003c/em\u003e: Partial correlations with bootstrapping were conducted to evaluate the relationship between KP and QoL while controlling for self-reported PA from the PAQ-A. Results showed that higher KP was significantly associated with poorer overall QoL (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.558, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and cardiac QoL (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.520, p\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePA and QoL\u003c/strong\u003e \u003cp\u003eAs reported elsewhere[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], higher self-reported PA from the PAQ was associated with better generic QoL (\u003cem\u003eτ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.270, p\u0026thinsp;=\u0026thinsp;.002), physical function (\u003cem\u003eτ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.265, p\u0026thinsp;=\u0026thinsp;.003), and emotional functioning (\u003cem\u003eτ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.233, p\u0026thinsp;\u0026lt;\u0026thinsp;.05). The PAQ was also significantly related cardiac specific QoL overall (\u003cem\u003eτ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.260, p\u0026thinsp;=\u0026thinsp;.003) and in the domains heart problems (\u003cem\u003eτ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.220, p\u0026thinsp;=\u0026thinsp;.013), physical appearance (\u003cem\u003eτ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.241, p\u0026thinsp;=\u0026thinsp;.011), and cognitive problems (\u003cem\u003eτ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.271, p\u0026thinsp;=\u0026thinsp;.002).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAdolescents with HD can become overly cautious and may self-restrict even moderate intensity PA out of fear of provoking an arrhythmia or \u0026ldquo;damaging their heart.\u0026rdquo; These fears are often learned and reinforced through explicit messages from clinicians and parents (e.g., strong symptom monitoring instructions) and through implicit learning when benign exertional sensations (e.g., palpitations, breathlessness) are interpreted as dangerous. Over time, this combination fosters hypervigilance, consolidates fear-avoidance behaviors, and drives progressive disengagement from PA, ultimately entrenching a sedentary lifestyle. To examine this mechanism quantitatively, we used the recently developed and validated TSK-Heart-A[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], a cardiac specific KP measure for adolescents with HD, to test relationships among HD-specific KP, PA, QoL, and PA self-efficacy. Incorporating this measure enables clinical research to isolate cardiac focused contributors to movement related- fear that generic anxiety or distress scales may miss, thereby clarifying actionable treatment targets. Prior work in this cohort has shown that higher PA relates to better QoL and fewer anxiety/depressive symptoms[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]; the present study extends those findings by jointly evaluating KP and PA self-efficacy\u0026mdash;two complementary, theoretically linked constructs that shape day-to- day PA engagement in pediatric HD.\u003c/p\u003e \u003cp\u003e \u003cb\u003eQuality of life findings.\u003c/b\u003e As anticipated, higher scores on the TSK-Heart-A were associated with poorer QoL on both the generic and cardiac specific PedsQL\u0026trade; measures, and these associations were most pronounced for patient reported physical functioning and heart problem domains. This pattern is conceptually coherent with the measure\u0026rsquo;s design history: in adapting the TSK for adolescents with HD, we deliberately emphasized heart related threat appraisals, activity linked danger beliefs, and avoidance of exertion in the item set to capture fear processes that are salient during everyday activity in this population. It follows that a scale organized around cardiac vulnerability during movement would correlate most strongly with domains that index physical capability and cardiac symptom burden. At the same time, it is important to underscore that TSK-Heart-A scores were also significantly related to all other QoL domains (including emotional, social, and school functioning). This broader pattern supports the view that KP is not merely a narrow exercise concern; rather, it reflects a more pervasive threat avoidance stance that can diffuse across daily roles, mood, peer engagement, and academic participation. Taken together, these results provide additional validation support for the TSK-Heart-A, suggesting the instrument aligns closely with physically and physiologically anchored aspects of functioning, as expected from its content focus; yet it also tracks general functional vulnerability that extends beyond the gym or sports field. Practically, this suggests the TSK-Heart-A may be useful both as a domain specific index of heart focused fear and as a proxy signal for broader PA-related functional impairment that clinicians should consider when planning counseling, clearance, or rehabilitation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSelf-efficacy findings and implications.\u003c/b\u003e We also observed a robust association between TSK-Heart-A scores and PA self-efficacy, and\u0026mdash;critically\u0026mdash;that this relationship persisted after controlling for PA. The persistence of this effect indicates- that the link between fear and efficacy is not reducible to whether adolescents are already active; it reflects how youth think about, interpret, and anticipate their capacity to be active in the context of HD. In other words, KP may undermine confidence in PA engagement\u0026mdash;dampening willingness to initiate or persist in PA even when current behavior levels are held constant. Conceptually, this positions self-efficacy as a resilience factor that can buffer the impact of fear and catastrophic appraisals on daily functioning[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Accordingly, intervention designs should not focus solely on reducing risk factors (e.g., fear, avoidance) but should also build strengths that facilitate action (e.g., graded mastery experiences, supportive performance feedback from clinicians and exercise professionals, peer modeling and group-based PA, and skills for reinterpreting benign exertional sensations). In concert with our findings linking KP to multiple QoL domains, targeting PA self-efficacy- is a potential treatment target for increasing day-to-day activity in pediatric HD. Within the broader literature, additional resilience-oriented constructs\u0026mdash;such as positive affect, intrinsic and autonomous motivation, and acceptance- -based responding to internal sensations[5; 12; 13; 37]\u0026mdash;also show promise as complementary targets. While global resilience has been associated with better exercise participation, mental health, and even lower healthcare utilization in pediatric HD[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], it remains unclear which specific components most directly support PA engagement in this population. The present finding\u0026mdash;that KP relates to self-efficacy independently of PA\u0026mdash;further suggests that effective PA programming will likely require more than prescribing additional exercise bouts. Programs may need to include structured cognitive behavioral- elements (e.g., graded exposure to exertion cues, cognitive reappraisal of interoceptive signals)[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], motivational strategies (e.g., goal setting with autonomy support), and family-inclusive coaching, so that adolescents not only do more PA but also feel more capable and safer doing it\u0026mdash;and can sustain those behaviors over time.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations and Future Direction\u003c/b\u003e. Despite the strength of using a cardiac specific- measure of KP tailored for adolescents with HD, several limitations warrant consideration and point to clear next steps. First, although the TSK-Heart-A total score has been validated, the putative subscales (e.g., \u003cem\u003efear of injury\u003c/em\u003e, \u003cem\u003eavoidance of exercise\u003c/em\u003e, \u003cem\u003eperceived danger for heart problems\u003c/em\u003e, and \u003cem\u003edysfunctional self\u003c/em\u003e) have not yet been psychometrically confirmed in adolescents.[3; 4]. Future work should formally evaluate these subdomains\u0026mdash;through factor analytic methods, reliability testing, and measurement invariance across age, sex, and diagnostic groups\u0026mdash;and determine clinically meaningful cut scores and responsiveness to change. Establishing valid subscales could clarify which fear related- processes matter most for which patients, directly informing targeted intervention components and clinical decision making. Second, this study relied on self-reported PA, which can introduce shared method- variance with other self-report outcomes (e.g., QoL) and potentially inflate associations. To reduce mono-method bias and improve precision, future studies should incorporate objective PA monitoring (e.g., accelerometry or activPAL) alongside validated self-report tools and harmonize analytic approaches to integrate device based- and perceived PA data. Third, the current sample was not powered to test more complex mechanistic models implied by the fear-avoidance framework (e.g., whether KP undermines PA self-efficacy, which then limits PA and, in turn, lowers QoL)[13; 45]. Larger, multisite and ideally longitudinal studies are needed to evaluate mediational pathways and directional effects, and to examine potential moderators (e.g., diagnosis category, treatment history) that could identify subgroups most likely to benefit from specific intervention strategies. Finally, we did not assess parent/caregiver factors. Given evidence that caregiver beliefs, anxiety, and protective behaviors shape youths\u0026rsquo; appraisals and behaviors, KP may be partly an interpersonal process in pediatric HD[1; 36]. Future research should include parent\u0026ndash;child dyads, assess caregiver KP and PA beliefs, and test family based- mechanisms of change. Addressing these limitations\u0026mdash;subscale validation, objective PA measurement, adequately powered mechanistic designs, and dyadic perspectives\u0026mdash;will sharpen construct fidelity and elucidate actionable treatment targets for next generation- interventions that integrate CBT/exposure, exercise training, and family education.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCardiac focused KP is a clinically meaningful construct that may help explain why many adolescents with HD under engage in PA and report lower QoL. Beyond its association with PA behavior, KP is independently related to lower PA self-efficacy and poorer QoL, highlighting the need to co target fear avoidance processes and efficacy building within pediatric cardiac rehabilitation and lifestyle counseling. This integrative, resilience-oriented approach has potential to improve psychosocial wellbeing and everyday functioning while supporting safe, lifelong activity in youth with HD.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contribution Statement:\u003c/strong\u003e All authors contributed to the origination and review of this manuscript. WRB and DAW led the initial conceptualization of the project. Data analyses were completed by WRB and EC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest and Disclosures:\u003c/strong\u003e The authors have no competing interest or disclosures to report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e Data will be available in aggregate upon request.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAsmundson GJ, Noel M, Petter M, Parkerson HA (2012) Pediatric fear-avoidance model of chronic pain: foundation, application and future directions. 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PLoS ONE 12(11):e0187668\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 3","content":"\u003cp\u003eTable 3 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pediatric, Heart Disease, Kinesiophobia, Physical Activity, Self-Efficacy","lastPublishedDoi":"10.21203/rs.3.rs-8322413/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8322413/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eKinesiophobia\u0026mdash;an excessive, often debilitating fear of movement or exercise\u0026mdash;has emerged as an important moderator of physical activity (PA) and has been linked with quality of life (QoL), anxiety, and depression in adolescents with heart disease (HD). This study explores additional factors that may be related to cardiac-focused kinesiophobia, including self-efficacy, PA engagement, and QoL.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSixty-three adolescents (mean age\u0026thinsp;=\u0026thinsp;15.5 years; 49% female) with congenital or acquired HD completed the TSK-Heart-A, the Physical Activity Questionnaire for Adolescents (PAQ-A), the Pediatric Quality of Life Inventory (PedsQL\u0026trade;) Generic Core and Cardiac Module, and the Domain-Specific Physical Activity Efficacy Questionnaire (DSPAEQ-A). Data were analyzed using Kendall\u0026rsquo;s Tau correlations and bootstrapped partial correlations controlling for PA.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eGreater kinesiophobia correlated with lower PA across both PA measures (τ = \u0026minus;.248), lower PA self-efficacy across household, leisure-time, and ambulatory domains (τ = \u0026minus;.293 to \u0026minus;\u0026thinsp;.356), and poorer QoL for both generic and cardiac scales (τ = \u0026minus;.403, \u0026minus;\u0026thinsp;.400). When controlling for PA, kinesiophobia remained significantly related to lower self-efficacy (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.314 to \u0026minus;\u0026thinsp;.368) and poorer QoL (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.558, \u0026minus;\u0026thinsp;.520)\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eCardiac-focused kinesiophobia is a salient psychological factor in pediatric HD. It is tied to lower PA and poorer QoL and is independently associated with reduced PA self-efficacy\u0026mdash;a modifiable resilience construct. These findings support the development of interventions that target fear-avoidance mechanisms and build self-efficacy to improve everyday activity and psychosocial functioning in adolescent HD.\u003c/p\u003e","manuscriptTitle":"Kinesiophobia, Physical Activity, and Physical-Activity Self-Efficacy in Pediatric Heart Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:36:22","doi":"10.21203/rs.3.rs-8322413/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-10T15:12:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-07T15:44:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39480143569844403339212030512738223133","date":"2026-01-07T14:40:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-29T19:15:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211270551056105857752341638834553318393","date":"2025-12-17T19:01:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-15T15:10:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-10T11:36:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-10T11:35:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Cardiology","date":"2025-12-10T03:03:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"173eb5cc-2585-4a17-b6d1-971873b12b8f","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:15:17+00:00","versionOfRecord":{"articleIdentity":"rs-8322413","link":"https://doi.org/10.1007/s00246-026-04182-7","journal":{"identity":"pediatric-cardiology","isVorOnly":false,"title":"Pediatric Cardiology"},"publishedOn":"2026-02-12 15:57:01","publishedOnDateReadable":"February 12th, 2026"},"versionCreatedAt":"2025-12-22 09:36:22","video":"","vorDoi":"10.1007/s00246-026-04182-7","vorDoiUrl":"https://doi.org/10.1007/s00246-026-04182-7","workflowStages":[]},"version":"v1","identity":"rs-8322413","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8322413","identity":"rs-8322413","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}