Chiropractic + Naturopathic Doctor • October 2019 • Research review

STUDY TITLE: Role of Kinesiophobia on Pain, Disability and Quality of Life in People Suffering from Chronic Musculoskeletal Pain: A Systematic Review

A total of 63 observational studies with a total of 10,726 participants were included. The results of the synthesis will be outlined based on the study designs listed below.

• Strong evidence exists demonstrating an association between a greater degree of kinesiophobia and greater levels of pain intensity and disability.

• There is moderate evidence for an association between a greater degree of kinesiophobia and greater levels of pain severity.

• There is moderate quality evidence for an association between greater levels of kinesiophobia and lower quality of life.

• Moderate quality evidence exists, demonstrating that a greater degree of kinesiophobia at baseline predicts the progression of disability immediately post-intervention, and at 3-, 6- and 12-month follow-ups, even after adjustment for age, gender, education level, comorbidities, BMI, pain severity, baseline disability levels, work status, marital status and disease severity.

• A greater degree of kinesiophobia at baseline predicts greater levels of pain severity at 6-month follow-up, with limited evidence.

• Greater levels of kinesiophobia at baseline predict lower QoL, with limited evidence.

• Conflicting evidence was found in support of kinesiophobia as a predictor of changes in pain intensity.

The authors performed a systematic review of cross-sectional and longitudinal studies to elucidate the relationship between kinesiophobia and pain, disability and quality of life. Specifically, cross-sectional studies showed strong evidence of an association between a greater degree of kinesiophobia and greater levels of pain intensity and disability; moderate evidence for an association between a greater degree of kinesiophobia and greater levels of pain severity; and moderate evidence for an association between greater levels of kinesiophobia and lower quality of life.

Longitudinal analysis of the prognostic role of kinesiophobia showed that higher baseline values of kinesophobia are associated with a higher disability over time; are predictive of higher pain severity at 6-month follow- up, with limited evidence; are predictive of lower QoL at 6-months, with limited evidence; and that kinesiophobia is a predictor of changes in pain intensity, with conflicting evidence. Unfortunately, causality could not be firmly demonstrated in the analysis, as there was a low total number of longitudinal studies which met the inclusion criteria. Because of this, the authors recommend that more longitudinal studies be performed.

The authors also acknowledge that kinesiophobia is a known modifiable barrier to rehabilitation adherence in various chronic pain conditions, that when appropriately treated can facilitate earlier achievement of pain relief and functional recovery. They advise that clinicians identify the presence of kinesiophobia prior to the prescription of any intervention, since its presence may require clinicians to take a holistic biopsychosocial approach to rehabilitation programming, such as selection of functional goals, education to manage safe behaviours and graded exposure to fearful activities.

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The PECOS (Patient Exposure Comparator Outcome Study design) framework was followed to determine which studies to include in the systematic review, based on the following inclusion criteria:

• Observational studies (cross-sectional, case control and longitudinal studies) exploring the predictive role of kinesiophobia in people with chronic MSK pain and their association with outcomes.

• Studies including adult participants with chronic MSK pain, defined in this review as persistent or episodic pain in the axial skeleton or peripheral joints, fibromyalgia, chronic myofascial pain, chronic widespread pain, RA, spondyloarthropathy or OA lasting > 3 months.

• English-language studies including patients from the general population, or primary, secondary or tertiary care.

• Studies that measured the association of kinesiophobia and pain, disability, and/or QoL.

• Studies of acute pain, subacute pain and chronic non-MSK pain according to the AAPT.

• Studies where chronic MSK pain was associated in the context of a major psychiatric disorder

• Studies evaluating kinesiophobia in chronic MSK pain attributed to fracture, pre- or post-surgery, trauma or using experimental models of pain.

• Studies testing kinesiophobia in the context of a behavioural task or treatment

Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS), which is known to measure selection bias, performance bias, detection bias and information bias. Each item is scored from 0 (high risk) to 3 (low risk), to a total maximum of 21 points. Qualitative analysis of the evidence was carried out using the Modified Cochrane Back and Neck Group rating system (strong evidence; moderate evidence; limited evidence; no-evidence found; and conflicting evidence categories).

Studies were grouped based on the outcomes of disability, pain and quality of life for the primary analysis. A meta-analysis could not be carried out due to heterogeneity of participant age, sample size, pain condition, outcome measures, version of self-reported kinesiophobia questionnaire (ex. TSK-11 or TSK-17), statistical methods utilized and study design.

• The authors registered their protocol on PROSPERO, used the PRISMA checklist through the development of the study, used the NOS checklist to evaluate risk of bias, and used the Modified Cochrane Back and Neck Pain Group Criteria to analyze the overall quality and strength of the evidence.

• The authors had a high number of included studies and large number of included participants, which enabled them to explore the role of kinesiophobia on pain, disability and QoL, and its impact on chronicity.

• Heterogeneity was present among all included studies, which limits the ability to perform a meta-analysis and to establish comparisons between studies.

• None of the included studies specifically evaluated the possible mediating effect of kinesiophobia in chronic MSK pain, and confounding variables were not always explored in all included studies.

• This review assessed one specific construct of fear (kinesiophobia). There are many other close, but not necessarily interchangeable constructs identified in the literature; readers should consider this when interpreting the results.

• The authors made many modifications from the initial registered protocol in PROSPERO.

• The authors only included studies which utilized the Tampa Scale of Kinesiophobia in their analysis. They did not include studies which used other questionnaires, such as the Fear Avoidance Beliefs Questionnaire.

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