With a View to Fear Extinction and to Brain Functional Change: A Neurotheoretical Hypothesis About Traditional Health-Preserving Exercises as Treatments for Post-Aortic Dissection Kinesiophobia
Post-aortic dissection kinesiophobia is one of the most frequent clinical problems—greatly impairing rehabilitation adherence-yet its neural underpinnings remain largely unexplained. Taking recent progress in studies of fear-related neural circuits (learning and extinction) as a basis, the present paper suggests that post-aortic dissection kinesiophobia corresponds to a conditioned fear phenomenon essentially of the type described with insufficient vmPFC inhibition and with an overactive amygdala, the present discussion proposes the “fear extinction-brain functional remodeling” neurotheoretical hypothesis: traditional health-preserving exercises-by virtue of their three-dimensional synergy (of body regulation, breath control, and mental calm)—help to regulate top-down vmPFC-amygdala activity, to optimize DMN functional connectivity and internetwork dynamics, to acquire and solidify fear extinction learning, and so to relieve kinesiophobia and to improve long-term prognosis. It now gives a systematic account of indirect evidence for this hypothesis and outlines multimodal fMRI studies as well as a mediation analysis research agenda.
[1] Tsao CW, Aday AW, Almarzoog ZI, et al., 2023, Heart Disease and Stroke Statistics–2023 Update: A Report from the American Heart Association. Circulation, 2023(147): e93–e621.
[2] Chen Y, Peng Y, Huang X, et al., 2024, Postoperative Kinesiophobia in Patients with Acute Type A Aortic Dissection: A Cross-Sectional Study. Reviews in Cardiovascular Medicine, 25(8): 304.
[3] Yang X, Luo Y, Wang D, 2026, Heterogeneity in Kinesiophobia among Postoperative Aortic Dissection Survivors: Associations with Exercise Self-Efficacy, Family Support, and Coping Styles. Frontiers in Psychology, 2026(17): 1800841.
[4] Caseras X, Mataix-Cols D, Trasovares MV, et al., 2010, Dynamics of Brain Responses to Phobic-Related Stimulation in Specific Phobia Subtypes. European Journal of Neuroscience, 32(8): 1414–1422.
[5] Huang MQ, Liang XL, Lin XT, et al., 2025, Amygdala-dependent Signaling Pathways and Regulating Circuits in Fear Memory. Synapse, 79(5): e70026.
[6] Bouton ME, Maren S, McNally GP, 2021, Behavioral and Neurobiological Mechanisms of Pavlovian and Instrumental Extinction Learning. Physiological Reviews, 101(2): 611–681.
[7] Johansen JP, Cain CK, Ostroff LE, et al., 2011, Molecular Mechanisms of Fear Learning and Memory. Cell, 147(3): 509–524.
[8] Xu R, Shi D, Wang K, et al., 2025, Progress in Spatiotemporal Regulation of Fear Memory: Neural Circuit Mechanisms and Implications for PTSD. General Psychiatry, 2025, 38(4): e102224.
[9] Rich M T, Sacko T J, Rohilla H K, et al. Fear conditioning enhances subsequent cocaine self-administration and amygdala neuronal activity only in male rats. Neuropharmacology, 2026, 298: 111079.
[10] Zhang X, Lan Z, Huang Y, et al., 2026, Identification of Somatostatin Inhibitory Engrams for Extinction in the Basolateral Amygdala. Proceedings of the National Academy of Sciences of the United States of America, 123(12): e2511528123.
[11] Lange I, Goossens L, Michielse S, et al., 2020, Neural Responses during Extinction Learning Predict Exposure Therapy Outcome in Phobia: Results from A Randomized-Controlled Trial. Neuropsychopharmacology, 45(3): 534–541.
[12] Lyons A L, Jiang X, Rawliuk T, et al., 2026, Ventromedial Prefrontal Cortex Activity during Extinction Recall Suggests Successful Extinction Learning via Mental Imagery. Social Cognitive and Affective Neuroscience, 21(1): nsag031.
[13] Andrys NRR, Johnson EA, Rowe EB, et al., 2026, Daily Rhythms in Fear Extinction Memory Reflect Structural and Functional Changes in a Prefrontal-Amygdala Circuit. Brain Structure & Function, 231(8): 136.
[14] Lu P, Chen D, Xia W, et al., 2025, Theta Oscillations between the Ventromedial Prefrontal Cortex and Amygdala Support Dynamic Representations of Threat and Safety. NeuroImage, 2025(310): 121164.
[15] Jin X, Chen J, Zhang X, 2026, Tai Chi Exercise and Neuroplasticity: A Narrative Review According to Neural Mechanisms and Clinical Utilizations in Brain Health. Frontiers in Neuroscience, 2026(20): 1769779.
[16] Zhang Y, Song Q, Li X, et al., 2026, Long-term Tai Chi Practice Modulates Cortical-Muscular Interactions during Walking in Older Adults: A Cross-Sectional Study. Clinical Interventions in Aging, 2026(21): 615470.
[17] Zhong X, Dai Z, Chu L, et al., 2026, Tai Chi Modulating Multimodal Connectivity Patterns and Cognitive Function in Cerebral Small Vessel Disease. Geroscience, 48(6): 7961–7976.
[18] Wang X, Si K, Gu W, et al., 2023, Mitigating Effects and Mechanisms of Tai Chi on Mild Cognitive Impairment in the Elderly. Frontiers in Aging Neuroscience, 2023(14): 1028822.
[19] Wang R, Chen J, Zhu D, 2026, Tai Chi Modulates Resting Alpha and Theta EEG Rhythms in Female Individuals with Amphetamine-Type Stimulant Dependence during Compulsory Detoxification. Frontiers in Psychiatry, 2026(17): 1904447.
[20] de Vos J H, Baldi S, Lange I, et al., 2026, Intrinsic Connectivity Networks during Fear and Safety Learning in Youth. British Journal of Psychiatry, advance online publication, 1–8.
[21] Das S, Meyyappan S, Bekker EM, et al., 2026, The Ventral Attention Network Mediates Attentional Reorienting to Cross-Modal Expectancy Violations: Evidence from EEG and fMRI. The Journal of Neuroscience, 46(7): e0720252026.
[22] Pacheco-Estefan D, Bouyeure A, Jacob G, et al., 2026, Representational Dynamics during Extinction of Fear Memories in the Human Brain. Nature Human Behaviour, 10(1): 29–48.
[23] Kida S, 2023, Interaction between Reconsolidation and Extinction of Fear Memory. Brain Research Bulletin, 2023(195): 141–144.
[24] Axmacher N, Pacheco-Estefan D, Bouyeure A, et al., 2026, Extinction Memories: Putting Learning into Context. Trends in Cognitive Sciences, 30(2): 107–109.
[25] Park H, Kaang BK, 2026, Role of the Hippocampus in Systems Consolidation of Remote Fear Memory. Experimental & Molecular Medicine, 58(4): 1010–1016.
[26] Kupke J, Loizou S, Bengtson CP, et al., 2025, Hippocampal DNA Methylation Promotes Contextual Fear Memory Persistence by Facilitating Systems Consolidation and Cortical Engram Stabilization. Biological Psychiatry, 98(5): 394–403.
[27] Wickramasuriya DS, Faghih RT, 2020, A Mixed Filter Algorithm for Sympathetic Arousal Tracking from Skin Conductance and Heart Rate Measurements in Pavlovian Fear Conditioning. PLoS One, 15(4): e0231659.
[28] Noble LJ, Chuah A, Callahan KK, et al., 2019, Peripheral Effects of Vagus Nerve Stimulation on Anxiety and Extinction of Conditioned Fear in Rats. Learning & Memory, 26(7): 245–251.
[29] Mary A, Nematollahi H, Torres D, et al., 2026, Transcutaneous Vagus Nerve Stimulation Enhances Episodic Memory Across Valences and Memory Stages. Brain Stimulation, 19(2): 103051.
[30] Phillips I, Johns MA, Pandža NB, et al., 2025, Three Hundred Hertz Transcutaneous Auricular Vagus Nerve Stimulation (taVNS) Impacts Pupil Size Non-Linearly as a Function of Intensity. Psychophysiology, 62(2): e70011.
[31] Bernetti C, D’Andrea V, Buoso A, et al., 2025, Arterial Spin Labeling MRI in Alzheimer’s Disease: A Systematic Review of Cerebral Perfusion Biomarkers. Journal of Neuroimaging, 35(2): e70035.
[32] Xue P, Yu H, Zhu Y, et al., 2026, Quantitative Perfusion Assessment with Arterial Spin Labeling Magnetic Resonance Imaging for Predicting Cognitive Decline in Alzheimer’s Disease: A Systematic Review and Meta-Analysis. Journal of Clinical Neuroscience, 2026(143): 111711.
[33] Fang Y, Zhang Y, Wang G, et al., 2025, Autonomic Function Effects on Postoperative Sleep Disorder: A Prospective Cohort Study. International Journal of Surgery, 111(10): 7010–7020.
[34] Akiya A, Takahashi K, Iwahara K, et al., 2026, Impact of Nonlinear Heart Rate Variability in Postoperative Complex Congenital Heart Disease: Insights from Repaired Tetralogy of Fallot and Fontan Palliation. Pediatric Cardiology, 47(5): 2241–2249.
[35] Zhao X, Zou R, Miao H, et al., 2026, The Efficacy of Traditional Chinese Exercises in Patients with Chronic Heart Failure: An Umbrella Review and Meta-Analysis. Reviews in Cardiovascular Medicine, 27(3): 46055.
[36] Wan Y, Fu Y, Bian Z, et al., 2026, Effects of Traditional Chinese Exercises for Upper-limb Dysfunction Following Breast Cancer Surgery: Protocol for a Systematic Review and Meta-analysis. BMJ Open, 16(5): e112564.
[37] Tanaka Y, Ito Y, Shibata M, et al., 2025, Heartbeat Evoked Potentials Reflect Interoceptive Awareness during an Emotional Situation. Scientific Reports, 15(1): 8072.
[38] Qi R, Wang J, Pei H, et al., 2026, Vagus Nerve Stimulation Enhances Memory and Long-term Potentiation via the Hippocampal NE/β-AR Signaling Pathway in Pilocarpine Rats. Brain Research Bulletin, 2026(237): 111789.
[39] Hyakumura T, Payne SC, Matarazzo JV, et al., 2025, Abdominal Vagus Nerve Stimulation Increases Firing in the Rat Locus Coeruleus. Neuromodulation, 28(8): 1239–1247.
[40] Driskill C, Vu L, Jalilvand S, et al., 2026, Pairing Extinction Training with Vagus Nerve Stimulation Reduces Drug-Seeking by Altering Activity in Afferents to the Medial Prefrontal Cortex. Frontiers in Neuroscience, 2026(20): 1756644.
[41] Noble DJ, Hochman S, 2019, Hypothesis: Pulmonary Afferent Activity Patterns during Slow, Deep Breathing Contribute to the Neural Induction of Physiological Relaxation. Frontiers in Physiology, 2019(10): 1176.
[42] Björkstrand J, Olsson E, Clancy OH, et al., 2026, Effect of App-Based Mindfulness on Extinction Recall—A 7T-fMRI Study. Scientific Reports, 16(1): 9957.
[43] Blades RB, Boyle CC, Eisenberger NI, et al., 2026, Neural Mechanisms of Mindfulness: Reduced Neural Reactivity to Social-Evaluative Threat Accounts for Mindfulness Intervention Effects on Inflammatory Gene Expression. Brain, Behavior, and Immunity, 2026(133): 106284.
[44] Liu X, Tang T, Liang S, et al., 2026, Effects of Tai Chi Combined with Transcranial Direct Current Stimulation on Pain in Knee Osteoarthritis: A Randomized Controlled Neuroimaging Trial. BMC Medicine, 24(1): 265.
[45] Kong J, Wolcott E, Wang Z, et al., 2019, Altered Resting State Functional Connectivity of the Cognitive Control Network in Fibromyalgia and the Modulation Effect of Mind-Body Intervention. Brain Imaging and Behavior, 13(2): 482–492.
[46] Ko YJ, Ko IG, 2020, Voluntary Wheel Running Improves Spatial Learning Memory by Suppressing Inflammation and Apoptosis via Inactivation of Nuclear Factor Kappa B in Brain Inflammation Rats. International Journal of Neurobiology, 24(Suppl 2): 96–103.
[47] Zhan Z, Pan L, Zhu Y, et al., 2023, Moderate-intensity Treadmill Exercise Promotes mTOR-dependent Motor Cortical Neurotrophic Factor Expression and Functional Recovery in a Murine Model of Crush Spinal Cord Injury (SCI). Molecular Neurobiology, 60(2): 960–978.
[48] Kolb H, Martin S, Kempf K, 2025, Traditional Health Practices May Promote Nrf2 Activation Similar to Exercise. International Journal of Molecular Sciences, 26(23): 11546.
[49] Wang J, Chen Y, 2025, Pain Catastrophizing, Kinesiophobia, and Exercise Adherence in Postoperative Cardiovascular Surgery Patients: The Mediating Role of Exercise Self-Efficacy. Journal of Rehabilitation Medicine, 2025(57): jrm43853.
[50] Kraal JJ, Peek N, Van den Akker-Van Marle ME, et al., 2014, Effects of Home-based Training with Telemonitoring Guidance in Low to Moderate Risk Patients Entering Cardiac Rehabilitation: Short-Term Results of the FIT@Home Study. European Journal of Preventive Cardiology, 21(2 Suppl): 26–31.
