Kinesiophobia, Physical Limitations and Psychological Distress as Barriers to Physical Activity in Heart Transplantation Patients: A Qualitative Study

<b>Background/Objectives</b>: Heart transplantation substantially improves survival and quality of life in patients with advanced heart failure; however, many heart transplantation patients fail to recover normal physical activity levels. Persistent inactivity compromises secondary prevention and long-term outcomes. Kinesiophobia-an excessive and irrational fear of movement-may act as a central barrier limiting physical activity after heart transplantation. This study aimed to explore how kinesiophobia develops and interacts with physical and psychological factors that influence adherence to an active lifestyle after heart transplantation. <b>Methods:</b> A qualitative study was conducted in 24 adult heart transplantation patients (mean age 62.1 years; 83% male) at a tertiary hospital in Spain. Semi-structured interviews lasting 35-60 min were transcribed verbatim and analysed using reflexive thematic analysis. Methodological rigour was ensured through triangulation, reflexivity, and transparent documentation of analytic decisions. <b>Results</b>: Three interrelated themes were identified: (1) Kinesiophobia, characterised by fear of overexertion and avoidance of performing physical activity; (2) physical limitations, including fatigue, muscle weakness, treatment side effects, and intensified perceptions of vulnerability; and (3) psychological distress, encompassing anxiety, demotivation, and frustration, which intensified inactivity. These domains formed a self-perpetuating cycle that restricted participation in physical activity. Some participants reported simple adaptive strategies, such as pacing, walking and social support that enhanced their sense of safety and confidence. <b>Conclusions</b>: Kinesiophobia, physical limitations, and psychological distress interact to restrict physical activity in heart transplantation patients. Our findings suggest that rehabilitation should integrate psychological support, cognitive-behavioural strategies, and tailored education to reduce fear, enhance self-efficacy, and promote sustainable physical activity engagement.