The situation of kinesiophobia during indwelling
During the indwelling, the limited limb movement of the implanted side was more common. 45.7% of patients had kinesiophobia (TSK≥18) with varying degrees and 18.5% had moderate to severe kinesiophobia (TSK≥25). Most of the patients were worried about the adaptation to activities when the infusion device was implanted, but the degree of fear was relatively mild compared with other chronic patients who were afraid of serious negative experience after the activities [9,10]. Some studies also had shown that the degree of kinesiophobia is related to education . Patients with lower educational level are more prone to fear, which may be related to the low financial ability to obtain medical resources . However, in this study, there was no significant correlation between the degree of kinesiophobia and factors of gender, age, educational level, tumor and heart disease. The reason may be related to the region of the subjects in this study, where the availability of and convenience to obtaining relevant medical information about the port is high due to a high level of economic development. Considering that the position of the catheter-tip would move in the superior vena cava in accord with respiration and limb movements, "whether the patient has heart disease" was included as an influencing factor, but the results showed that it was not correlated with the fear of movement (P=0.145), which may be related to the precise positioning of the tip during the operation and the fact that the patient's limb movements with the catheter did not cause cardiac discomfort. The duration of the indwelling of the infusion port had no effect on the degree of kinesiophobia of patients (P=0.415), the TSK score of patients with indwelling port had no difference between less than 1 month and more than 6 months. However, the fear of movement from patients with infusion ports continued until the infusion port was removed. The implantation site of infusion port did not affect the degree of motility of patients (P=0.167), regardless of the upper arm port or chest wall port. Meanwhile, no statistically significant effect on the degree of patients' motility was shown between left limb implantation and right limb implantation (P=0.809) in our study.
A study  have shown that non-right-handed infusion port implantation should be the first choice when the patient is right-handed, which can reduce the potential detrimental impact of infusion port implantation to the quality of life. However, a trans-left infusion port implantation will reduce the duration of the use of the infusion port and increase the risk of catheter-related thrombosis [14,15]. Meanwhile, trans-left infusion port implantation is inconvenient for operators. It is suggested that infusion ports should be comprehensively evaluated before implantation, and patients should be fully communicated with. The implanted side should be selected after weighing the advantages and disadvantages.
Activity cognition and attitude of tumor patients during indwelling
The score of activity cognition and activity attitude was higher than that of activity behavior, indicating that the kinesiophobia was mainly manifested in psychological cognition during the period of indwelling. The items with high scores were “My accident has put my body at risk for the rest of my life " and " I’m afraid that I might injure myself if I exercise", indicating that the patient's fear of moving was due to his concern about the safety of catheter. According to a study of indwelling experience , when it comes to daily life situations, catheter is described as a continuous reminder of disease and discomfort. Although most patients do not think the port has negative effects on the body, they still feel repulsive about it. Fatigue and low mood will also increase the discomfort of tumor patients with port and will be linked to negative outcomes of the port such as poor satisfaction and treatment compliance . Medical staff should be reminded of paying attention to the psychological experience, emotional changes and coping styles of tumor patients during indwelling, and carry out necessary interventions as early as possible. For patients who use cognitive avoidance as a coping strategy, the problem will exacerbate. Medical staff can play an important role in correcting adverse coping types and avoiding harmful dispositions. Psychological education interventions for patients and their families can help develop better cognitive and behavioral strategies to better adapt patients’ daily life to vascular access devices.
Regression analysis showed that exercise habits were an important factor influencing the fear of motility (P=0.025). Patients with exercise habits (19.08±6.27 points) had a higher TSK-11 score than those without exercise habits (17.02±5.79 points). It may be related to the fact that the patients who have the habit of exercise are involved in a greater range and intensity of activities, and they are more concerned about whether the infusion port will break or turn due to the activity. Proper physical exercises are beneficial to the survival and quality of life of cancer patients , and it can help reduce the incidence of complications such as thrombosis and shoulder dysfunction caused by infusion devices implanted. A systematic review about the influence of fear of movements on the outcome of total knee replacement showed that although the effect on the outcome of postoperative rehabilitation was complicated, the presence of kinesiophobia would have a negative impact on the outcome of limb function up to one year .
It is suggested that medical staff should include the evaluation of exercise habits of patients into the comprehensive evaluation before they decide which limb to be operated on, so as to meet the exercise needs of patients during their stay with the port. In the health guidance, nurses should fully consider that the physical strength of tumor patients, a special group, will be affected by diseases and treatment , and offer different activity and exercise guidance for different groups. We should not only reduce fears and concerns of limb activities caused by TIAPs for our patients, but also make them be aware of the possible harm caused by vigorous arm swings and other movements during the catheterization, so as to truly meet the needs of different groups and improve their quality of life.
Pain and foreign body sensation
Both pain and foreign body sensation are related to the subjective negative experience from patients, including local pain caused by surgery and each injection of port needle, unexplained pain during catheter placement, visual experience and touch sensation of port protruding under the skin, and pulling sensation of large movements. These experiences cause patients to pay more attention to the extent and scope of their activities during the indwelling of the infusion port , leading to their fear of movements. Clinical practices have proved that infusion port is a better device for cancer patients for their treatment. But in some patients, the implant can lead to emotional distress, anxiety and depression, which may be related to patients' individual differences, and sensitivity to the physical symptoms [21,22]. Particularly, the visibility of infusion port further reminds patients of their illness.
Medical staff should fully reduce the pain of patients when performing the surgery and injecting needles into the infusion port , and strengthen postoperative health education, including avoiding heavy lifting in the first week after implantation and informing patients that normal activities of the limbs on the surgical side can be carried out. Patients with positive personalities can maintain internal control over medical strategies and more likely to accept the negative influence of implants. Patients with negative personalities have less confidence in the treatment effect and are more sensitive to discomfort and complications. Therefore, medical staff should help and encourage patients to increase their abilities of coping with disease cognition and behaviors.
Limitations and recommendations for future research
Some limitations to our single center cross-sectional study are worth noting. We were unable to determine the true effect of temporal changes on kinesiophobia and subsequent influence on physical activities. Data with multicenter trials will be needed to prove our conclusion.