Effects of Exercise Training on Fear-Avoidance in Pain and Pain-Free Populations: Systematic Review and Meta-analysis

Background: Fear of pain and movement is an important factor in the development of hypervigilance and avoidance behaviours. Objective: We examined the effectiveness of exercise training on improving fear-avoidance beliefs. Methods: A systematic review (data sources: MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL) and metaanalysis of randomised controlled/clinical trials of exercise training in adults versus relevant nonexercise comparators that quantified fear-avoidance was conducted. Results: After screening 4603 identified records, 17 (2014 participants) and 13 (1152 participants) studies were eligible for qualitative and quantitative synthesis, respectively. Pairwise meta-analysis showed exercise training was more effective than all non-exercise comparators (standardised mean difference (SMD) [95% CI] − 0.378 [− 0.623, − 0.133], P = 0.002, Grading of Recommendations Assessment, Development and Evaluation [GRADE]: very low) for reducing fear-avoidance. Exercise training was more effective than true control for reducing fear avoidance (− 0.407 [− 0.750, − 0.065], P = 0.020, GRADE: very low), however it was not more effective than other interventions (− 0.243 [− 0.614, 0.128], P = 0.199, GRADE: very low). In people with low back pain, exercise training was more effective than non-exercise comparator groups for reducing fear-avoidance (− 0.530 [− 0.755, − 0.304], P < 0.001, GRADE: very low). For individuals with neck pain, exercise training was not more effective than non-exercise comparator groups for reducing fear-avoidance (0.061 [− 0.360, 0.482], P = 0.777, GRADE: very low). Conclusion: There is very low to low-quality evidence that exercise training is effective for reducing fear-avoidance, including in people with low back pain. Exercise training may be more effective than no intervention for reducing fear avoidance, but there is very low-quality evidence that non-exercise interventions are as effective as exercise for fear avoidance. Few studies with low risk of bias is a limitation. Trail Registration: PROSPERO Registration Number: CRD42019139678.