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

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Abstract

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.

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Acknowledgements

The authors thank Josh Defazio for his assistance in the project in screening of the titles/abstracts and full-texts. Scott Tagliaferri is supported by an Australian Government Research Training Program (RTP) Scholarship.

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Authors and Affiliations

  1. Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Geelong, VIC, 3125, Australia

    Joshua Hanel, Patrick J. Owen, Scott D. Tagliaferri, Clint T. Miller & Daniel L. Belavy

  2. German Sports University Cologne, Am Sportpark Müngersdorf 6, 50933, Cologne, Germany

    Steffen Held & Lars Donath

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  1. Joshua Hanel
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Contributions

Secured funding: NA; Study conception: Belavy, Donath, Owen, Miller; Screening: Held, Defazio; Extraction: Hanel, Held; Statistical analyses: Hanel, Owen, Tagliaferri; Drafted manuscript: Hanel; Revised manuscript for intellectually important content: Owen, Held, Tagliaferri, Miller, Donath, Belavy; Approved final manuscript: All.

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Correspondence to Daniel L. Belavy.

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No funding was received for the performance of this work.

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The authors declare no conflicts of interest.

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The data extracted as part of this systematic review and used in subsequent analysis is made available in Table 1.

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Hanel, J., Owen, P.J., Held, S. et al. Effects of Exercise Training on Fear-Avoidance in Pain and Pain-Free Populations: Systematic Review and Meta-analysis. Sports Med 50, 2193–2207 (2020). https://doi.org/10.1007/s40279-020-01345-1

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