Measurement of Exercise Avoidance and False Safety Behaviors in Older Adults - PROJECT SUMMARY/ABSTRACT
Aging-related changes to the structure and function of the heart increase vulnerability to cardiovascular
disease (e.g., heart disease, stroke), frailty, falls, dementia, and Alzheimer disease. Exercise-based cardiac
rehabilitation (CR) slows these processes, reduces risk of mortality, and improves physical function and quality
of life. However, most patients who enroll in CR fail to gain the full benefits of treatment due to poor attendance
and adherence, and few maintain independent physical activity when CR treatment ends. Exercise anxiety is a
novel mechanism related to non-adherence to exercise and lifestyle physical activity that is characterized by
cognitive, behavioral, and physiological underpinnings. Exercise anxiety is particularly elevated in patients
enrolled in CR given that physical sensations of exercise often feel similar to sensations attributed to
cardiovascular disease (e.g., shortness of breath, racing heart). Heightened awareness of these bodily
sensations can promote fear and worry about what could happen during exercise (e.g., “What if I have a heart
attack?”), even though it is both safe and recommended for patients to engage in aerobic exercise. Patients may
avoid exercise and/or rely on false safety behaviors to manage fears (e.g., checking pulse frequently,
restricting speed on treadmill). While these behaviors relieve anxiety in the moment, they exacerbate and
maintain anxiety long-term. Through repeated use, individuals learn to attribute “safety” to their avoidance and
safety behaviors, developing false beliefs that safety is contingent upon certain actions (e.g., “It’s only safe for
me to exercise when someone is monitoring my heart”), which maintain their fears and unnecessarily limits
their activities (e.g., “I can’t go for a brisk walk unless someone is keeping an eye on me”). Despite theoretical
and clinical relevance, there is currently no reliable and valid measure to identify and track these exercise
avoidance and false safety behaviors for targeted treatment, which leaves patients vulnerable to the
misperception that it is only safe to exercise under a restrictive set of circumstances and results in limited
physical conditioning and functioning. This study will fill this critical assessment gap through the two following
aims. Aim 1: To characterize exercise avoidance and safety behaviors in CR via comprehensive literature
review, expert focus groups, and clinical behavioral observation for generation of an initial item bank to be
used for development of a self-report scale. Aim 2: To refine and evaluate the psychometric properties of scale
items in a sample of patients enrolled in CR through exploratory factor analysis and item reduction, followed by
confirmatory factor analysis and tests of item reliability and validity in a subsequent sample. This study will
have an immediate impact on efforts in promotion of CR adherence and fearless aging by developing a self-
report measure of exercise avoidance and false safety behaviors for use in both research and intervention
efforts. This measure will facilitate systematic identification and treatment of fear-avoidance and false safety
behaviors that undermine CR adherence and active independent living.
