Martinez-Calderon J, Flores-Cortes M, Morales-Asencio JM, et al. Conservative Interventions Reduce Fear in Individuals With Chronic Low Back Pain: A Systematic Review. Arch Phys Med Rehabil. 2020 Feb;101(2):329-358. doi: 10.1016/j.apmr.2019.08.470. Epub 2019 Aug 29. (Systematic review)

OBJECTIVE: To systematically review and critically appraise the effectiveness of conservative and surgical interventions to reduce fear in studies of people with chronic low back pain, based on the analysis of randomized controlled trials for which fear was a primary or secondary outcome.

DATA SOURCES: Electronic databases PubMed, CINAHL, PsycINFO, PEDro, and CENTRAL, as well as manual searches and grey literature were searched from inception until May 2019.

STUDY SELECTION: Randomized controlled trials analyzing the effectiveness of conservative and surgical interventions to reduce fear were included.

DATA EXTRACTION: Two reviewers independently conducted the search strategy, study selection, data extraction, risk of bias assessment, and quality of the evidence judgment.

DATA SYNTHESIS: Sixty-one studies (n=7201) were included. A large number of fear-related search terms were used but only 3 fear constructs (kinesiophobia, fear-avoidance beliefs, fear of falling) were measured in the included studies. Multidisciplinary and psychological interventions as well as exercise reduced kinesiophobia. Fear-avoidance beliefs were reduced by the aforementioned interventions, manual therapy, and electrotherapy. A multidisciplinary intervention reduced the fear of falling. There was moderate evidence of multidisciplinary interventions and exercise to reduce kinesiophobia. There was moderate evidence of manual therapy and electrotherapy to reduce fear-avoidance beliefs.

CONCLUSIONS: The present systematic review highlights the potential effectiveness of conservative interventions to reduce kinesiophobia and fear-avoidance beliefs in individuals with chronic low back pain. This information can help health professionals to reduce fear when treating patients with this condition.

Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

Fear reduction is uncommonly explored as an outcome measure for conservative and surgical interventions for back pain. In the few studies that have explored this, there are some associations of note: reduced kinesiophobia and fear of falling with multidisciplinary interventions and fear avoidance with multidisciplinary, psychological and exercise interventions. Further research is needed to understand these associations and their relationship to quality of life and work re-entry outcomes.

Physician rater

The systematic review has not assessed the validity of the patient reported outcome measures (PROMs) used in the included as primary and secondary outcomes. A checklist developed by the COSMIN can be used in this context. Therefore, the validity of the results of the present might be questionable, if the used PROMs do not possess adequate psychometric properties: first of all high content validity, next adequate statistical psychometric measurement properties.

Rehab Clinician (OT/PT) rater

As a physiotherapists who treats chronic low back pain, I find most became chronic as a result on increased fears caused by various health care providers seen in the past. This paper shows that it is possible to REDUCE fear, therefore help recovery.

Rehab Clinician (OT/PT) rater

I was surprised to see the minimal impact of psychotherapy techniques on fear as this has not been my experience as an OT in clinical practice. The authors need to be cautious when suggesting PRs lead psychotherapy based treatments as psychotherapy is now a restricted act in many jurisdictions requiring formal training that PTs do not have.

Rehab Clinician (OT/PT) rater

Systematic review demonstrates that a range of conservative interventions are effective in reducing fear in people with chronic low back pain. This finding can inform the delivery and future development of such interventions and may well be considered for its relevance to other clinical specialties.

Rehab Clinician (OT/PT) rater

Two quotes from the conclusions. One most people would know, "there was moderate evidence of multidisciplinary interventions and exercise to reduce kinesiophobia." The other probably most would not know. There was "moderate strength of evidence regarding the reduction of fear-avoidance beliefs by electrotherapy, and manual therapy".
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