Research Review By Dr. Demetry Assimakopoulos©

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Date Posted:

August 2019

Study Title:

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

Authors:

Luque-Suarez A, Martinez-Calderon J & Falla D.

Author's Affiliations:

Departmento de Fisioterapia Universidad de Malaga, Malaga, Spain; Department of Physiotherapy, University of Malaga, Malaga, Spain; Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation, Birmingham, UK.

Publication Information:

British Journal of Sports Medicine 2019; 53: 554-559.

Background Information:

MSK-related pain is a highly prevalent and costly condition (1) and is the second most common cause of disability in the general population (2). A myriad of biopsychosocial factors is associated with poor recovery from an acute painful episode. Chief among these contributing elements are negative or maladaptive psychological factors, such as fear avoidance beliefs and kinesiophobia (3-6).

The fear-avoidance (FA) model of pain is one popular framework, created to explain the development and persistence of pain and disability following acute injury (7, 8). The FA model stipulates that individuals with fear and catastrophic thoughts in response to pain are at greater risk of developing chronic MSK pain after an injury (9). These individuals tend to over-react in response to actual or potential threats and develop avoidance behaviours with the intent of preventing/avoiding new injury or re-injury. There is no specific tool (or questionnaire) for assessing fear of movement, apart from the clinical encounter itself.

Kinesiophobia (aka fear of movement) is defined as an excessive, irrational and debilitating fear of performing physical movements due to a perceived vulnerability to injury or re-injury. It is often assessed by administering the Tampa Scale of Kinesiophobia questionnaire. Kinesiophobia is very similar to the construct of fear avoidance beliefs and has essentially the same clinical relevance. Kinesiophobia can be acquired through a direct aversive experience (ex. pain or trauma) or social learning (observation and instruction) and may be associated with increased pain and negative outcomes. Not surprisingly, there is an exceedingly high prevalence of kinesiophobia in chronic pain populations (50-70%). While fear and escape behaviours are defensive and adaptive in the short term, avoidance activities can become maladaptive in the long term, leading to deconditioning, emotional distress, greater pain, disability, and as a result, poor quality of life.

The authors of this systematic review sought to explore the level of association between kinesiophobia and pain, disability and quality of life (QoL) in people with chronic musculoskeletal pain, and to analyze the value of kinesiophobia as a prognostic factor.

Pertinent Results:

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.

Cross-Sectional Analyses:
  • 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.
Longitudinal Analyses:
  • 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.

Clinical Application & Conclusions:

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.

REVIEWER’S NOTE: Given the fact that I primarily work with patients suffering from chronic pain, I must say that acknowledgement of kinesiophobia is of vital importance. Many clinicians are ironically “fearful” of treating kinesiophobic patients and believe these patients to be suffering from some form of psychological/psychiatric disorder. Clinicians should be reminded that there is a difference between kinesiophobia and anxiety. Take the time to get to know your patient and assess them thoroughly. If you suspect a high amount of anxiety, administer a GAD (Generalized Anxiety Disorder) -7 Questionnaire. If your patient has a high score, then co-treatment with a qualified mental health professional might be necessary. In the absence of an overt anxiety disorder, manual therapy/rehab clinicians are perfectly suited to provide treatment. Even psychologists agree that the best place for kinesiophobic patients to be is in the gym being gradually exposed to fearful tasks, learning to control symptoms and to gain self-efficacy. I am also a HUGE advocate for educating patients on the fear-avoidance beliefs paradigm, and how/why it is important to confront fears to facilitate recovery. Above all, kinesiophobic patients are deserving of empathy and patience.

Study Methods:

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.
  • Studies measuring kinesiophobia with the TSK questionnaire.
  • 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.
The exclusion criteria were as follows:
  • 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
  • Reviews, clinical studies, case reports, editorials and abstracts.
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.

Study Strengths / Weaknesses:

Strengths:
  • 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.
Weaknesses:
  • It is possible that not all relevant studies were identified.
  • 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.

Additional References:

  1. Cimmino MA, Ferrone C & Cutolo M. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol 2011; 25: 173–83.
  2. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012; 380: 2163–96.
  3. Gorczyca R, Filip R & Walczak E. Psychological aspects of pain. Ann Agric Environ Med 2013; 1: 23–7.
  4. Keefe FJ, Rumble ME, Scipio CD, et al. Psychological aspects of persistent pain: current state of the science. J Pain 2004; 5: 195–211.
  5. Severeijns R, Vlaeyen JWS, van den Hout MA, et al. Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Clin J Pain 2001; 17: 165–72.
  6. Sullivan MJL, Thorn B, Haythornthwaite JA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain 2001; 17: 52–64.
  7. Leeuw M, Goossens MEJB, Linton SJ, et al. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007; 30: 77–94.
  8. Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000; 85: 317–32.
  9. Lundberg M, Styf J. Kinesiophobia among physiological overusers with musculoskeletal pain. Eur J Pain 2009; 13: 655–9.