Author Names
Kamonseki, D. H., Christenson, P., Rezvanifar, S. C., & Calixtre, L. B.
Reviewer Name
Juliana Ancalmo, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Objective: To systematically review the effectiveness of manual therapy on fear-avoidance, kinesiophobia, and pain catastrophizing in patients with chronic musculoskeletal pain. Literature search: Databases (Medline, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and SCOPUS) were searched from inception up to March 2020. Study selection criteria: Two reviewers independently selected randomized controlled trials that investigated the effects of manual therapy associated or not with other interventions on fear-avoidance, kinesiophobia and pain catastrophizing in patients with chronic musculoskeletal pain. Data synthesis:
Standardized Mean Differences (SMD) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model for meta-analysis according to the outcome of interest, comparison group and follow-up period. The level of evidence was synthesized using GRADE. Results: Eleven studies were included with a total sample of 717 individuals. Manual therapy was not superior to no treatment on reducing fear-avoidance at short-term (low quality of evidence; SMD = -0.45, 95% CI -0.99 to 0.09), and intermediate-term (low quality of evidence; SMD = -0.48, 95% CI -1.0 to 0.04). Based on very-low quality of evidence, manual therapy was not better than other treatments (SMD = 0.10, 95% CI -0.56 to 0.77) on reducing fear- avoidance, kinesiophobia (SMD = -0.12, 95% CI -0.87 to 0.63) and pain catastrophizing (SMD = -0.16, 95% CI -0.48 to 0.17) at short-term. Conclusion: Manual therapy may not be superior to no treatment or other treatments on improving fear-avoidance, kinesiophobia and pain catastrophizing, based on very low or low quality of evidence. More studies are necessary to strengthen the evidence of effects of manual therapy on pain-related fear outcomes.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
Yes - Were eligibility criteria for included and excluded studies predefined and specified?
Yes - Did the literature search strategy use a comprehensive, systematic approach?
Yes - Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes - Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes - Were the included studies listed along with important characteristics and results of each study?
Yes - Was publication bias assessed?
No - Was heterogeneity assessed? (This question applies only to meta-analyses.)
Yes
Key Finding #1
Manual therapy was not found to be superior to other treatments on reducing fear-avoidance, kinesophobia and pain catastrophizing with small effect size on patients with chronic musculoskeletal pain at short-term (less than 3 months) follow-up, based on very low quality of evidence.
Key Finding #2
Based on two study’s findings, manual therapy was found to have no statically significant difference to no treatment on reducing fear-avoidance at short-term and intermediate-term (3- 12 months) follow-ups on patients with chronic musculoskeletal pain, with moderate effect size and based on low quality of evidence.
Please provide your summary of the paper
This paper is a systematic review and meta-analysis conducted to analyze the current literature regarding the use of manual therapy to reduce fear-avoidance, kinesiophobia and pain catastrophizing in individuals greater than 18 years old with chronic musculoskeletal pain. This is the first systematic review to verify the effects of manual therapy on these psychological outcomes measures and examine the quality of literature provided. After conducing electronic searches and narrowing down the results through the eligibility criteria, 11 studies were included in this meta-analysis. Participants of all studies were all 18 years or older and had complaints of chronic, defined as longer than 3 months, musculoskeletal pain of any kind. The eligible studies included manual therapy of any kind, not including dry needling, that was either applied alone or along with graded exposure therapy or therapeutic exercise, and was compared to either no treatment or other treatment. Other treatment included cognitive functional therapy, therapeutic exercise or physical agents. After statically analysis was performed, the results showed manual therapy was found to have no statically significant difference to no treatment on reducing fear-avoidance at short-term and intermediate-term, with moderate effect size and based on low quality of evidence. For the other outcomes measured, there was no statistically significant difference between manual therapy and other treatments on reducing fear-avoidance, kinesophobia and pain catastrophizing with small effect size at short-term follow-ups, based on very low quality of evidence. Due to the limited number of studies included within this meta-analysis, the authors discuss the inability to draw conclusions regarding the effectiveness of manual therapy in reducing these psychological and behavioral outcome measures. However, the authors hope future research regarding the impact of these treatments on these measures can be further explored.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The results of this study demonstrate that there is no statistically significant difference between manual therapy and other forms treatment in reducing fear-avoidance kinesiophobia and pain catastrophizing. Therefore when treating patients with chronic musculoskeletal pain who also present these psychological components, clinicians can recognize that based on these results, manual therapy may not be any more helpful in reducing these psychological outcome measures than other forms of treatment. However, the quality of studies included in this meta- analysis were low with small effect sizes found, and therefore definitive conclusions regarding the effectiveness of manual therapy on these outcomes cannot be made. Clinicians should still use their own clinical reasoning and consider patient preferences when determining appropriateness of manual therapy use for a patient.
