Rehabilitation Interventions for Fear-Avoidance Beliefs and Behaviors in Sudden Onset Musculoskeletal Conditions: A Scoping Review

Abstract

Fear avoidance (FA) describes beliefs and behaviors related to avoiding movements or activities after a painful event. Fear avoidance is a prevalent issue that limits the recovery outcomes and social reintegration of burn survivors. However, as current literature focuses on chronic conditions, understanding the impact and treatment of FA within sudden onset musculoskeletal (MSK) conditions, specifically in the burn survivor population, is lacking. The purpose of this scoping review is to synthesize evidence-based rehabilitation interventions aimed at improving FA behaviors and beliefs after sudden onset MSK conditions and to provide suggestions for clinical application with the burn survivor population. Ovid Medline, Ovid EMBASE, CINAHL, and PsycINFO were sourced from inception to May 2023. Monthly Google Scholar searches and hand-searching of included articles’ reference lists were done to add additional relevant publications. Eligibility criteria included: (1) adults with sudden onset MSK condition, (2) intervention from a rehabilitation professional, and (3) FA as the primary outcome. Four authors performed data extraction using the TIDIER checklist. Seven intervention types were identified: (1) education; (2) exercise; (3) graded motor imagery; (4) manual therapy (MT); (5) multimodal—education with exercise; (6) multimodal—education with MT and exercise; and (7) multimodal—interactive gaming console with exercise. All intervention types, except MT, demonstrated significant decreases in FA. This review summarizes effective rehabilitation interventions to address FA while highlighting the role of rehabilitation professionals in improving function and alleviating potential disability stemming from FA despite physical recovery.

INTRODUCTION

Fear avoidance (FA) is when an individual avoids a specific activity, occupation, or movement based on fear, which can manifest after a painful event or injury.¹ Fear avoidance is an umbrella term that includes, but is not limited to, avoidance due to social fears, smells, sounds, environments, activities, or movements (kinesiophobia). It can also be induced by individuals within their social environment, such as family members, healthcare professionals, or friends. Individuals with FA avoid engaging in activities or situations that either trigger a painful physical sensation or are associated with the initial painful event, which results in activity limitations, disruption of important life activities, and overall negative affect.² This fear may persist even after physical recovery from the pain-inducing event and has the potential to result in long-term disability.³

The ways in which FA creates disability have been investigated for more than 40 years. Based on the consolidation of this literature, Vlaeyen and colleagues² have updated the original model¹ where increased attention and negative appraisal of pain as highly threatening leads to prioritizing pain control. Fear is the immediate emotional response to an eminent threat, but if escape and avoidance behaviors are adopted, the fear remains despite the healing that has occurred.² Increased psychophysiological reactivity and anticipation of pain may also trigger generalization of avoidance behaviors of other situations.⁴ In the long-term, continued avoidance of activities may increase negative mood, impair functioning, and contribute to experiencing long-term disability.⁵

Indeed, a study by Waddell et al.⁶ demonstrated that FA beliefs regarding physical activity and work were strongly associated with disability. In another study by Linton & Buer⁷, it was shown that FA scores could be used as an important discriminating factor between people who were on considerable sick leave (an average of 25 days) for back pain and those who were able to continue working.

Since Lethem et al.¹ proposed the concept of FA to explain how back pain can transition to chronic pain, the majority of the literature has focused on chronic conditions, such as chronic low back pain and neck pain.^8–10 Fear avoidance, however, can also emerge in the acute phase of an injury, but may be harder to identify at this stage since immobilization is sometimes necessary to promote tissue healing.⁵ When this acute FA is left unaddressed, it may then develop into chronicity and disability.⁵ As such, more research has begun examining FA after traumatic injuries, such as burns,¹¹ anterior cruciate ligament (ACL) tears,¹² and whiplash-associated disorders (WAD),¹³ to allow for further understanding and development of interventions to adequately equip clinicians to identify patients with FA earlier. The recognition that FA is prevalent in between 50-70% of clients with persistent pain further reinforces that it is vital that healthcare professionals are prepared to address FA.¹⁴

Specifically, the presence and impact of FA in the recovery and rehabilitation process of burn survivors has been increasingly recognized as a significant barrier, as a burn injury is frequently associated with a highly traumatic event and often results in extreme pain for an extended period of time.^11,15,16 In fact, a patient-reported outcome measure called the Burn Survivor Fear-Avoidance Questionnaire has been developed in recent years to evaluate FA beliefs and behaviors in burn survivors. This measure aims to appropriately identify and address this issue during recovery¹⁷ and has been shown to moderately correlate with pain early post-injury, but the strength of the correlation reduces with time. So as has previously been proposed in non-burn populations, fear of movement within the acute stage of recovery can be expected, since it may serve as a protective mechanism.² However, once this cycle begins when the pain reduces, the fear does not. In addition, the FA of burn survivors strongly correlated with catastrophizing across time and with disability at later points in time.¹⁷

Rehabilitation healthcare professionals, such as occupational and physical therapists, are well placed to identify and address FA, as they often follow patients for extended periods of time with the goal of reestablishing patient function and minimizing disability. Furthermore, their mandate requires the consideration of psychosocial factors alongside physical factors that may affect a patient’s recovery process.¹⁸ They can thus incorporate 2 methods to address FA within their practice: as a primary intervention to improve functional outcomes, and as a secondary intervention to reduce the likelihood of disability.^9,19,20 Addressing FA has been shown to be an effective primary intervention in increasing function compared to control groups whose FA was not directly addressed by rehabilitation therapists.⁹ A potential explanation for this significant change in function is that addressing fear of pain and pain catastrophizing consequentially impacts patient-reported levels of pain intensity, chronicity of pain, and disability.²¹ Addressing FA directly is also beneficial in counteracting negative effects of pain catastrophizing such as decreased participation in one’s activities and reduction in self-efficacy.²² On the other hand, addressing FA can also be an effective secondary prevention method of disability for people with acute injuries that have been identified as being likely to develop chronicity.²⁰ By addressing FA early in their rehabilitation, those with high FA risk factors have been shown to develop less disability with early intervention than those receiving standard care.²⁰

Current reviews on FA mainly focus on chronic conditions, or single interventions in specific populations,^23,24 which are not directly applicable to burn survivors. There is a need to synthesize knowledge on rehabilitation techniques to address FA beliefs and behaviors in individuals with burn injuries, but relevant literature for this population is limited. To address this gap, our scoping review was expanded to include rehabilitation interventions for patients with sudden onset musculoskeletal (MSK) conditions. These patients share a common experience of sudden, painful, and often traumatic changes in their musculoskeletal function—such as strength, mobility, and endurance—that substantially impact their independence.^25,26 Additionally, treatments like surgery and dressing changes can exacerbate and prolong their pain.²⁷ These similarities suggest that interventions effective for sudden onset conditions may provide a starting point for the development of evidence-informed protocols that can be the basis for further investigations. The aim of this review is to examine the existing literature on rehabilitation interventions that target FA beliefs and behaviors in-patient populations with acute musculoskeletal injuries. Findings from relevant studies will be synthesized to inform rehabilitation practices for patients with sudden onset MSK conditions, including those with burn injuries.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR)²⁸ was used to generate an audit trail of the scoping process and to outline this review. The scoping review was conducted in accordance with the 5-step procedure outlined by Arksey and O’Malley,²⁹ with the adaptations from Levac et al.³⁰

Stage 1: Identifying the research question

The final research question that guided this review was: What rehabilitation treatment interventions are proposed to address fear-avoidance beliefs and behaviors in patients with sudden onset acquired MSK conditions?

Stage 2: Identifying relevant studies

Search strategy

All authors designed a search strategy (Appendix 1) that was validated by a McGill University librarian and used for the following databases: Ovid Medline, Ovid EMBASE, CINAHL, and PsycINFO from their earliest date of coverage to May 2023. The search strategy used subject headings related to FA in conjunction with subject headings related to rehabilitation professionals to identify studies relevant to the research question.

Hand searching was performed on reviews (scoping/systematic reviews and meta-analyses) that were found through the initial search, and relevant articles were included in the pool of identified studies. Further hand-searching was conducted with the references of the full-text studies included. Finally, monthly Google Scholar searches were conducted from May 2023 until submission to ensure no new relevant article was missed.

Inclusion/exclusion criteria

See Table 1.

Table 1.

Scoping Review Question and Inclusion/Exclusion Criteria

Research question: What rehabilitation treatment interventions are proposed to address fear- avoidance beliefs and behaviors in patients with sudden onset acquired conditions?
Inclusion criteria	Exclusion criteria
Interventions provided by rehabilitation professionals (eg, occupational therapists, physical therapists) Must focus on fear-avoidance as a primary outcome Adult subjects only Musculoskeletal condition, with sudden onset - Musculoskeletal injuries (eg, sudden onset back pain, fracture) - Post-operative pain (eg, hip/knee replacement) - Physical trauma (eg, burns) - Idiopathic conditions with somatosensory symptoms (eg, brachial plexus avulsion) - Fibromyalgia (with traumatic origin) - Complex regional pain syndrome (with traumatic origin) Acceptable alternative terms for FA: avoidance, kinesiophobia, apprehension, movement avoidance, movement-related fear, avoidance behaviors/behaviors, fear of pain, pain avoidance, pain- related anxiety, fear of injury, fear of movement Sufficient detail to be replicable by clinicians: must have provided detail for the “What” and “How” sections of the TIDIER (Template for Intervention Description and Replication) checklist24 Any type of studies or grey literature other than reviews Any geographical location English or French	Interventions provided by non- rehabilitation professionals (eg, psychologist) No fear avoidance, or fear avoidance as a secondary outcome Pediatric subjects Non-musculoskeletal condition or condition without sudden onset: - Acquired neurological conditions (eg, stroke) - Sudden onset conditions (eg, Guillain-Barre Syndrome) - Cancers - Psychological conditions (eg, bipolar disorder, depression, anxiety, post-traumatic stress disorder) - Degenerative diseases (eg, osteoarthritis, rheumatoid arthritis, multiple sclerosis) - Genetic conditions (eg, Down syndrome) - Neurodevelopmental conditions (eg, cerebral palsy) Insufficient detail to be replicable: missing details in the “What” and “How” sections of the TIDIER checklist24 Reviews (scoping, systematic and meta-analysis) Published in any language other than English or French

Stage 3: Selecting studies

All article citations from the database searches were imported into a reference manager software program (Endnote 20, Clarivate Analytics, Pennsylvania, USA) to remove duplicates. The remaining citations were then divided into 2 groups using Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia). Two pairs of authors (J.L./J.F. and T.S./E.K.) independently screened the title/abstract of half of the identified articles. Conflicts were then resolved between the 2 authors. Of this pool of articles, the topics were broad and did not adequately answer the research question. Therefore, it was determined that a second round of title/abstract screening was necessary with the addition of a stricter inclusion criteria: a sudden onset MSK condition. Conditions such as stroke and cancers, were consequentially excluded. These articles still did not sufficiently answer the research question and therefore the reviewers conducted a third round of title/abstract screening, ensuring that FA was a primary outcome of the study. The teams were switched during this round to reduce bias (J.F./E.K. and J.L./T.S.). Full agreement was reached following a discussion between the 2 authors of each team.

Full-text screening was conducted in the same manner as title/abstract, with each team of 2 taking half of the articles.

Stage 4: Charting the data

The following data were collected from the articles and summarized into a data extraction table (Table 2): first author/date, study design, sample, treatment type, country, intervention, outcome measure, results, and conclusion. The intervention column was filled using the TIDIER (Template for Intervention Description and Replication) checklist as a system to organize the extracted data.³¹ This ensured thorough and consistent descriptions among reviewers as well as made the extraction more rigorous. If details were missing from the TIDIER checklist,³¹ but the article met all of the inclusion/exclusion criteria, the authors were contacted to gather further information to ensure replicability. The checklist was then condensed to present the most relevant data directly related to FA outcomes.

Table 2.

Data Extraction Table

First author, date	Design	Sample	Treatment tpe	Country	Intervention (Tidier)	Outcome measures	Results	Conclusion
Brewer et al., 2022 (32)	RCT	n = 69 scheduled for ACL surgery - Tx group n = 34 - Control group n=35 - Mean age = 35.01 ± 11.98	Education (Virtual)	USA	Tx group: - Virtual interactive, multimedia program including videos and resources to prepare the patients for surgery and the subsequent rehabilitation - Videos included anatomy overview, explanation of surgery and rehab procedure, pre-op and post-op exercises, narratives of former ACL surgery patients, etc. - Additional resources of program (online and printed): breathing exercises, tips to prepare for surgery and adhere to rehabilitation, rehabilitation journal for goal setting and tracking, questions to ask the surgeon, etc. - Prior to beginning Tx, participants were introduced to the program in the office, then given a CD-ROM of the program to bring home. Control group: - Read and took home a standardized set of printed educational materials1 1  Knee Ligament Injuries: Diagnosis and Treatment by Krames	TSK-17	TSK scores (pre-op, 1 m, 2 m, 3 m, 4 m, 5 m, 6 m) - Tx group: 25.67 to 21.42 to 20.42 to 21.00 to 19.00 to 18.00 to 17.92b - Control group 2: 25.60 to 23.33 to 24.40 to 24.87 to 23.73 to 22.80 to 21.47	TSK scores of Tx group were significantly lower than those of control group across the 6 m assessment period. Interactive multimedia program is associated with less kinesiophobia over the first 6 m of post-op rehab
Cetinkaya Eren et al., 2022 (33)	RCT	n = 31, THR surgery - Tx group VADE n=13, mean age = 49.61 ± 9.52 - Tx group PT n = 18, mean age = 55.33 ± 11.83	Education (PT vs video-assisted discharge education (VADE))	Turkey	Tx group VADE: - Received IP post-op PT session of breathing exercises, hip ROM and strengthening exercises, positioning, and info about walking and ambulation - Received PT booklet with info covered in-session and exercises to be continued for 12 wks - Received IP post-op VADE and info booklet that included education on THR, preventative rehab approaches, transfer activities, using stairs, and self-care activities. PT was present to answer questions during video screening. Tx group PT: - Received same PT session as VADE Tx group	TSK (Turkish version)	TSK (post-Tx) - Tx group VADE: 39.38 +/– 8.13c - Tx group PT: 48.05+/– 6.59a	Tx group VADE had significant ↓ in kinesiophobia compared to Tx group PT
Baez et al., 2021 (34)	RCT	n = 12 female participants, history of ACLR (>1 year post-op) - Tx group IVET n = 6 - Sham group n = 6 - Mean age = 22.5 ± 4.6	Education (Video-based in vivo exposure therapy (IVET))	USA	Tx group IVET: - In vivo graded-exposure therapy of fear-eliciting situations - 30-min coaching sessions 1x/wk over 4 wks, during which they practiced 3 movement progressions through fear-eliciting situations based on items of the PHOSA-ACLR2 - Progression of movements graded up according to clients’ self-rated fear level - Patients encouraged to practice movements at home 2x30min/wk - Video shown wk 1 on rationale of CBT and Graded Exposure as Tx for FA, importance of active coping and positive self-talk. Sham group: - Weekly step log: document PA levels measured through daily number of steps using a pedometer 2  https://link.springer.com/content/pdf/10.1186/s12891-017-1643-9.pdf	TSK-11, PHOSA-ACLR	TSK (pre- to post-Tx) Tx group IVET: 20.33 to 17.83 Sham group: 22.17 to 21.83 PHOSA-ACLR (pre- to post-Tx) Tx group IVET: 1.85 to 1.04c Sham group: 1.96 to 1.55	Statistically significant and clinically meaningful main effect for time (effect size = 0.50) was observed for the PHOSA-ACLR for both groups, suggesting that both in vivo exposure therapy and PA monitoring led to ↓ injury-related fear.
Russo et al., 2017 (35)	RCT	n = 110 cemented TKA - Tx group A n = 52 - Tx group B n = 50 - Mean age = 69.1 ± 13.0	Education (Videoinsight—art video promoting self-confidence and psychological support)	Italy	Tx group A: - Underwent PT program implemented within first 15d post-op, 3x/wk for 4 wks. Included assisted ROM and partial weight bearing (2x60min/d for 10d) - Watched a therapeutic art video promoting self-confidence and psychological support daily prior to PT sessions - Watched the video at home 3x/wk for 1st 3 m post-op Tx group B: - Underwent same PT program as Tx group 1 without viewing video	TSK-17	TSK (pre- to post-Tx) - Tx group A: 36 ± 8 to 24 ± 5c - Tx group B: 38 ± 6 to 29 ± 5c	Tx group A showed significant ↓ kinesiophobia compared to Tx group B.
Burton et al., 2020 (36)	RCT	n = 18, CAI - Tx group Clin-mob n = 8 - Tx group Self-mob n = 10 - Mean age = 20.78 ± 2.02	Exercise vs MT	USA	Tx group Clin-mob: -6 sessions over 2 wks performed by AT - Four sets of Maitland grade III anterior-to-posterior talocrural joint mobs each session Tx group Self-mob: - 6 sessions over 2 wks supervised by AT - Four sets of repetitive oscillations using weight-bearing lunge position to mobilize lead ankle or using a mob belt	FABQ-PA, TSK-11	FABQ-PA (pre- to post-Tx) - Tx group Clin-mob: 10.5 to 8 - Tx group Self-mob:10.5 to 7 TSK-11 (pre- to post-Tx) - Tx group Clin-mob: 20 to 19 - Tx group Self-mob: 19.5 to 15.5	No significant Δ in Tx group Clin-mob. Non-significant ↓ FA and kinesiophobia in Tx group Self-mob.
Bunketorp et al., 2006 (37)	RCT	n = 47 WADs - Tx home group n = 25, mean age = 35 ± 12 - Tx supervised group n = 24, mean age = 38 ± 11	Exercise (Home exercises or supervised PT sessions)	Sweden	Tx home group: - 2x/d home exercises for cervical muscles - Received 4 sessions of counseling with a PT about the home program Tx supervised group: - 2x/wk, 1.5 hour supervised PT session, average of 18 sessions total in study period -Exercises for cervical muscles - Program was individually tailored and graded over time under PT supervision Both groups provided info pamphlet about self-management and recuperation through PA.	TSK-17	TSK (Δ0-3 m and Δ0-9 m) - Tx home group: 20c and 16b - Tx supervised group: 50c and 9b	Significant ↓ FA in Tx supervised group compared to Tx home group.
Dudhani et al., 2020 (38)	RCT	n = 60, post-op lumbar degenerative diseases - Tx group n = 30, mean age = 46.3 to 55.5 - Control group n = 30, mean age = 47.3 to 56.5	GMI	India	Tx group: - 2x/wk sessions for 3 wks - Laterality training: R/L discrimination with the Recognize Back app - Watched 2 videos and imagined themselves performing movements shown - Localization training: patients were stimulated on an area of their back by therapist and asked to locate stimulation on a lumbar spine grid - Sensory discrimination: patients were stimulated on an area of their back with either a sharp or blunt instrument and asked to identify type of stimulation - Graphesthesia: patients asked to identify number or letter drawn on their back - Two-point discrimination: therapist-applied alternate pressure using aesthesiometer on patients’ back as patients identified number of pressure points Control group: - No active intervention other than post-op exercises.	FABQ	FABQ (pre- to post-Tx) - Tx group: 51.23 to 23.63c - Control group: 53.20 to 41.90a	Significant ↓ FABQ score in Tx group compared to control.
Salik Sengul et al., 2021 (39)	RCT	n = 38, lumbar spinal surgery - Tx group n = 19, mean age = 50 - Control group n = 18, median age = 58	GMI	Turkey	Tx group: - Pre-op education: how to use corset post-op, effects of surgery, anesthesia, and preparing participants for mob post-op - IP exercises: deep breathing, ankle pumping exercises, early progressive mob - Home exercises: neutral spine and maximum voluntary isometric contraction exercises for gluteus maximus, rectus abdominis and quadriceps femoris. Exercises tailored to participants and progressed over time. Completed 1x/day for 6 wks - Received recordings to listen prior to performing home exercises that guided them through visualizing performing home exercises without physically executing them - Recording was updated weekly to follow participants’ progression through exercises Control group: - Received same pre-op education, IP and home exercises as Tx group	TSK-17	TSK (pre-Tx, 3 wks, 6 wks) - Tx group: 48 to 43 to 41c - Control group: 45.5 to 42.5 to 42.5	Significant ↓ kinesiophobia in Tx group compared to pre-Tx.
Coban et al., 2022 (40)	RCT	n = 30, arthroscopic shoulder repair 6/52 post-op - Tx group n = 15, mean age = 52.84 ± 7.44 - Control group n = 15, mean age = 57.20 ± 7.04	MT (Fascial release technique)	Turkey	Tx group: - Conventional PT program: 2x/wk for 2 wks. Hot pack, interferential current, and exercises. - Home program: hourly passive joint movement for affected shoulder - 1x60min myofascial release session. Therapist-applied pressure while patient is stationary or asked to move a single joint. Control group: - Received same conventional PT program and home program as Tx group	TSK-17 (Turkish version)	TSK (pre- to post-Tx) - Tx group: 45.07 ± 7.17 to 40.30 ± 7.14a - Control group: 44.00 ± 7.60 to 44.60 ± 6.89	Tx group showed only statistically significant ↓ FA. No significant difference in TSK scores between two groups post-treatment.
Eymir et al., 2022 (41)	RCT	n = 106 TKA - Tx group PMR n = 55, mean age = 68 - Tx group SR, n = 51, mean age = 66	Multimodal—Education (PMR) combined with exercise (Progressive muscle relaxation (PMR))	Turkey	Tx group PMR: - Performed SR program + additional PMR program - Performed PMR exercises after SR program - Patient education session: 1h session 1-2d pre-op. Patients listened to PMR audiotape and performed exercises under PT supervision. - Following surgery, PMR exercises performed 2x30min/d - PMR Exercises: sustained muscle group contraction for 5s then relaxation for 10-15s, progressing through all muscle groups of body Tx group SR: - SR program 2x30min/d during IP stay SR program = Knee active-assisted ROM exercises, isometric and isotonic strengthening exercises, functional exercises for transfers, gait training, walking + home exercise program given post discharge (2x/d)	TSK-17	TSK (pre-Tx, discharge, 3 m post-op) - Tx group PMR: 43.0 to 34.5 to 29.0c - Tx group SR: 48.0 to 40.0 to 33.0c	Tx group PMR had significant ↓ kinesiophobia at discharge compared to Tx group SR. No significant difference at 3 m.
Ilves et al., 2017 (42)	RCT	n = 98 patients with spondylolisthesis who have undergone lumbar fusion Tx group LSF-EX n = 48, mean age = 59 ±12 Tx group LSF-UC n = 50, mean age = 58 ±12	Multimodal—Education combined with exercise program	Finland	Tx group LSF-EX: - 2-3/wk sessions over 12 m beginning at 3 m post-op with PT - Progressive home-based back-specific and aerobic training together with fear avoidance counseling. - Exercises to train specific muscle groups (abdominal, gluteal, thigh, low back) with elastic bands. - Progressive walking training encouraged - Booster sessions offered during program: identify and discuss barriers to physical exercise with patient (kinesiophobia, pain) by exploring experiences with previous phase of program in order to instruct for following phase Tx group LSF-UC: - One guidance session with PT 3 m post-op. - Provided verbal, pictorial and written educations for standard home exercises: light muscle endurance exercises, stretching, and balance training. - Advised to perform exercises at home 3x/wk	TSK-17	TSK (pre- to post-Tx) - Tx group LSF-EX: 32.5 to 31.5 - Tx group LSF-UC: 30.0 to 29.5	No significant Δ in kinesiophobia in either group.
Johansson et al., 2009 (43)	RCT	n = 59, lumbar-disc surgery with no previous spinal surgery or comorbidities - Tx group clinic-based n = 29, mean age = 43 - Tx group home-based n = 30, mean age = 38	Multimodal—Education combined with exercise program (Clinic-based behavior-oriented physiotherapy program vs home-based exercise program)	Sweden	Tx group clinic-based: - 1x/wk over 8 wks with PT - behavioral-operant approach including graded activity with positive reinforcement of healthy behavior - Exercises: mobility, trunk stability, stretching, strengthening, graded resistance exercises, and general conditioning by treadmill walking - Active coping styles encouraged - Barriers to activity identified and discussed; alternatives to painful exercises given - Continual emphasis of importance for future regular PA, and patients established goals Tx group home-based: - Same exercises as clinic-based group given 3 wks post-op to perform at home with recommendation to grade up as they progress - No additional education provided - Able to contact PT with questions during program	TSK-17 (5 omitted questions)	TSK (pre-Tx, 3 m, 12 m) - Tx group clinic-based: 31 to 20 to 20 - Tx group home-based: 33 to 22 to 24 Clinical significance not measured due to 5 omitted questions.	Statistically significant Δ kinesiophobia observed between two treatment groups at 12 m. This Δ was not clinically significant.
Lu et al., 2021 (31)	RCT	n = 78 with kinesiophobia after TKA - Tx group n = 39, mean age = 69.28 ±6.85 - Control group n = 39, mean age = 68.79 ±5.80	Multimodal—Education combined with exercise program (micro-video intervention via WeChat)	China	Tx group: - 1x/d post-op over 7d in hospital - Broadcasting of mobile micro-videos through WeChat by rehab professional. - Included simultaneous cognitive belief education and exercise behavior education - Micro-videos disseminated in 3 parts: actionable exercises goals, detailed demonstration of exercise movement, and peer and healthcare support education. - Exercises included single-joint movement, simple muscle exercises, and multi-joint movement Control group: - Received regular in-person education from rehab professional - Include ankle pump exercise, quadriceps muscle contraction exercise, knee joint bending, and straight leg raising exercise - Instructed to grade amount per degree of muscle fatigue	TSK-17	TSK (d1, d3, d7) - TX group: 38.58 to 36.00a to 33.66a - Control group: 38.61 to 36.80a to 35.75a	No significant Δ kinesiophobia observed between control vs Tx group.
Parker et al., 2016 (44)	RCT	n = 22 IP burn patients, with total burn surface area of ≤10% . - Tx group n = 12, mean age = 26 - Control group n = 10, mean age = 34.5	Multimodal—Interactive Gaming Consoles combined with exercise program	Australia	Tx group: - Tx over 7d - Exercise program: PT-performed accessory mobs and assisted range gaining techniques (as per burn location), exercises targeting core stability and cardiorespiratory training. - Received access to a series of Wii fit/sports games to be played 20-30 mins, 2x/d for 4-5d total. Patients were given initial coaching on how to play games and techniques to reduce compensatory movement patterns. Control group: - Tx over 7d - Received same exercise program as Tx group	PASS	PASS median scores (pre- to post-Tx) -Tx group: Escape/Avoidance 23 to 18 Fearful reappraisal 17 to 14.5 Physiological anxiety 16 to 16 -Control group: Escape/Avoidance 22 to 24.5 Fearful reappraisal 15.5 to 14 Physiological anxiety 19.5 to 14	No significant Δ of median pain-related anxiety between control vs Tx group
Romero& Pratt, 2019 (45)	CR	n = 1, 53 yo female with acute hip pain after falling at work	Education (PNE)	USA	Tx: - 3 in-person sessions with PT - Involved “ Painful Yarns” by Lorimer Moseley, “ Dangers in Me,” and “ Safeties in Me.” - First visit: pain science education using concepts from “ Painful Yarns,” identifying personal dangers and safeties, and addressing the dangers. - Second visit: focused on improving function and prescribed a home program - Third visit: creating a treatment plan that simulated work activities and involved the patient in decision-making processes to reduce fears No control group	FABQ-PA, FABQ-W	FABQ-PA: 15 to 0b FABQ-W: 33 to 6b	Significant ↓ in FA in both PA and work aspects. Early intervention of PNE and empowerment along with usual care were found to be successful in ↓ FABs, ↑ function, and returning to work rapidly in acute hip pain
Toomeyet al., 2021 (46)	CR	n = 1, 44 yo female, with CLBP and left anterior thigh pain following fusion surgery 12 years ago	Multimodal—Education (PNE) combined with MT and exercise program	New Zealand	Tx: - Seen 1x/wk for 12 wks - Received PNE: discussing soreness following exercise and MT, pain beliefs and attention, differentiating between pain and bodily harm and active management of pain - Exercise: compound movements (pushing, pulling, bending, squatting), coached in-session with further practice done by client 2x/wk - MT administrated during wks 1-2 and again at wk 5 No control group	FABQ-PA	FABQ-PA -18 to 4c Scores maintained at 12-wk f/u	Significant ↓ in FA for participant. MT played a crucial role in addressing FA beliefs, and relating the exercises of the program to ADLs was very helpful to establish relevance for the patient whilst counseling FA behaviors
Brindisino et al., 2020 (47)	CR	n = 1, PHF + massive rotator cuff tear with surgery refusal, age = 90	Multimodal—Education (PNE) combined with MT and exercise program	Italy	Tx: - PT sessions over 3.5 m - PNE by teaching about pain from a neurobiological and neurophysiological perspective. - Education on anatomic aspects of rehab, best rehab strategies for whole arm, home program behavior, safe return to ADLs - MT sessions: grade 2 Maitland mobs, glenohumeral traction, inferior gliding technique, mob with movement, thoraco-scapular aspecific mob - Supervised exercises: low-grade anterior flexion, abduction resisted isometric exercises, retraining of teres minor and deltoid muscle - Home program: self-assisted mob and isometric contraction exercises graded over time. As rehab progressed, supervised exercises were added to home program. No control group	FABQ-W, FABQ-PA	FABQ-W: 37 to 7c FABQ-PA: 24 to 6c	Significant ↓ in FA was noted post interventions. PT was essential in facilitating optimum recovery in patients with PHF treated conservatively. Patient’s function and beliefs regarding clinical condition ↑ steadily throughout program
Zimney et al., 2014 (48)	CR	n = 1, 19 yo, lumbar strain with R LE radicular pain	Multimodal—Education combined with MT and exercise program (TNE, MT, sensory neuromodulating techniques, home program)	USA	Tx: - 5 sessions over 2 wks provided by PT and occupational medicine physician - Graded over time and tailored for client - TNE: 20 min 1:1 initial session, 5-10 min refreshers in subsequent sessions. Focused on educating about pain mechanisms. - MT: Maitland joint mob grade II-III and neurodyamic mobs. - Sensory neuromodulating techniques: dermoneuromodulation and Kinesio taping - Home program (4-6x/d): gentle neurodynamic mobility supine hook lying trunk rotation technique and seated slump sliders No control group	FABQ-PA, FABQ-W	FABQ-PA (pre- to post-Tx) -23 to 0c FABQ-W (pre- to post-Tx) -30 to 0c	Significant ↓ FA observed for participant
Van Oosterwijck et al., 2011 (49)	Single-case Study	n = 6, WADs (Grades I and II) Mean age = 35.7 ± 7.3	Education (PNE)	Belgium	Tx group: - 2x30min Individualized sessions - Patients meet with therapists 1:1 to learn about pain centralization and interaction between stress, pain cognition and pain behavior/perceived pain3 - The Neurophysiology of Pain Test was administered prior to second session to ensure patients properly understand concepts discussed No control group 3 Explain Pain by Mosely and Butler, 2003	TSK-17 (Dutch version)	TSK (Pre- to post-Tx) - 38.61 ± 4.85 to 33.29 ± 7.80a	Significant ↓ kinesiophobia observed.
Powdenet al., 2019 (50)	Single-case study	n = 20, self-reported CAI - Mean age = 24.35 ± 6.95	Exercise	USA	Tx group: - Supervised component: 12 sessions of 30-45min over 4 wks with an AT. Maitland grade 3 anterior-to-posterior talocrural joint mobs, proprioceptive neuromuscular facilitation ankle strengthening and balance training; graded over time - Home component: 15min/d, gastrocnemius-soleus stretch and ankle strengthening; graded over time. No control group	FABQ-W, FABQ-PA	FABQ-PA (baseline, pre-Tx, post-Tx, 2 wks post-Tx) - 13.50 to 12.60 to 6.50c to 5.65c FABQ-W (baseline, pre-Tx, post-Tx, 2 wks post-Tx) - 8.75 to 5.20 to 2.40c to 4.35a	Significant ↓ in FA for FABQ-PA at post-Tx and 2 wks post-Tx, and for FABQ-W at post-Tx.
Wong et al., 2016 (51)	Pre-post pilot test	n = 5 with unilateral amputations of mixed etiology and level - Mean age = 54	Exercises (Program of MT, exercise, and functional training)	USA	Tx group: - MT, exercise, and functional training program - 1x/week for 4 total sessions - Exercises: MT grade III to IV hip mob, hip flexor stretching, gluteal and abdominal stabilization exercises, static and dynamic balance activities - Functional prosthetic mobility training - Supervised walking with turns (20 sit-to-stand reps) - No home exercise or educations provided. No control group	Subjective fear of falling numeric scale	Initial and final fear of falling scores on the subjective fear of falling numeric scale: - Subject A: 7 to 0 - Subject B: 7 to 7 - Subject C: 8 to 5 - Subject D: 0 to 0 - Subject E: 4 to 0	Large effect size ↑ observed for fear of falling (-0.82). A large effect size is considered to have a value >0.8.
Coronado et al., 2020 (25)	Open pilot study	n = 8, ACL injury and surgery mean age = 20.1 ± 2.6	Education (Cognitive-behavioral-based physical therapy (CBPT-ACLR))	USA	Tx group: - 7 sessions (one pre-op, 1x/wk over 6 wks post-op) conducted by a licensed PT via telephone - Pre-op session “ What to Know Before Surgery” includes information to inform on injury and prepare patients for surgery, healing process, ADLs, and introduces controlled breathing strategies - Post-op sessions inform and introduce CBPT strategies such as grounding/relaxation and graded activity plan, athletic identity, monitoring self-talk, setting daily intention and present-mindedness, managing setbacks, and guided imagery No control group	TSK-13	TSK (pre-op and 6 m post-op) - Patient 1: 36 to 29b - Patient 2: 36 to 32 - Patient 3: 24 to 18b - Patient 4: 34 to 29b - Patient 5: 20 to 16 - Patient 6: 31 to 31 - Patient 7: 21 to 13b - Patient 8: 30 to 22b	5/8 patients significant ¯TSK from pre-op to 6m post-op A telephone-delivered CBPT-ACLR program is a feasible and acceptable intervention for addressing psychological risk factors after ACL surgery.

Abbreviations: ACLR = Anterior Cruciate Ligament Reconstruction, ADL = activity of daily living, AT = athletic trainer, CAI = chronic ankle instability, CBT = cognitive-behavioral therapy, CBPT = Cognitive-Behavioral Physical Therapy, clin-mob = clinician-applied joint mobilization, CLBP: chronic low back pain, CR = case report, CS = case series, d = day, FA = fear avoidance, FABQ = fear-avoidance beliefs questionnaire, FABQ-PA = fear-avoidance beliefs questionnaire physical activity subscale, FABQ-W = fear-avoidance beliefs questionnaire work subscale, f/u = follow-up, GMI = graded motor imagery, info = information, IP = in-patient, IVET = in vivo exposure therapy, LBP = lower back pain, LE = lower extremity, LSF-EX = lumbar spine fusion exercise, LSF-UC = lumbar spine fusion-usual care min = minute, m = month, mob = mobilization, MT = manual therapy, PA = physical activity, PASS = Pain Anxiety Symptoms Scale, PCS = pain catastrophizing scale, PGAP = Progressive Goal Attainment Program, PHF = proximal humerus fracture, PHOSA-ACLR = Photographic Series of Sports Activities for Anterior Cruciate Ligament Reconstruction, PNE = pain neuroscience education, post-op = post-operative, pre-op = pre-operative, PT = physical therapy/physical therapist, RCT = randomized controlled trial, rehab = rehabilitation, ROM = range of motion, self-mob = self-mobilization, SR = standard rehabilitation, THR = total hip replacement, TKA = total knee arthroplasty, TNE = therapeutic neuroscience education, TMJ = tempero mandibular joint, TSK = Tampa Scale of Kinesiophobia, Tx = treatment, VADE = video-assisted discharge education, WAD = whiplash-associated disorder, y = year, /52 = per week, /12 = per month, wk = week.

^aStatistically significant change.

^bClinically significant change.

^cBoth statistically and clinically significant change.

The table was created through a shared Excel spreadsheet, which allowed all team members to input relevant extracted data from included articles. Data extraction was an iterative process. Prior to the beginning of the data extraction phase, the authors performed a data extraction calibration exercise where they extracted the data of 2 articles into the table and compared their findings together in order to standardize the information analysis. If an article reported FA as its main outcome but also simultaneously reported on other outcomes, then only the data relative to FA was extracted into our table (Table 2). In accordance with Levac et al.’s³⁰ guidelines, 4 reviewers independently extracted their assigned respective articles (between 5 and 8 articles each) and submitted their input in the data extraction form. Each author then conferred with a second author (E.K./J.F. and J.L./T.S.) to ascertain whether their extraction was congruent with each other in addition to being in line with the research question and objectives. The process of independent extraction, then collaborative consensus generation, was continued for the entire data extraction portion of the project.

Stage 5: Summarizing and reporting results

The 3 steps from Levac et al.’s³⁰ Stage 5 were followed: analyzing the data, reporting the results, and applying meaning to the results. Similarities in treatment type were analyzed and grouped thematically in Table 2. The studies that reported statistical significance and clinically important differences of FA outcome measures were outlined in Table 2. For studies that did not report clinically important differences of their measures, only statistical significance was extracted from the study. We then reported the clinically important differences of the FA outcome measure used based on the psychometric studies of those assessments.^32–34 If a study reported an effect size, it was included in Table 2. Effect sizes are used to describe the practical significance of interventions and can be interpreted as small (<0.20), moderate (0.50), large (0.80), and very large (>1.30) effects according to Cohen’s criteria.^35,36

Interpretation and discussion of results as recorded in the extraction table was conducted through roundtable talks amongst authors. These discussions sought not only to provide commentary on numerical results, but also to isolate trends within results that may be applicable to clinical application of FA interventions with patient populations with sudden onset MSK conditions.

RESULTS

Description of studies

The PRISMA flowchart for this review is presented in Figure 1. At the end of the first round of title/abstract screening, there were 932 articles. Following the second round of screening, there were 658 articles left. After the third round, 220 articles remained, and the authors had an 88% agreement. At the end of the full-text screening process, the authors had a 90% agreement, with the full agreement being reached after discussion between the 2 authors of each team.

Figure 1.

PRISMA Flowchart for Search and Study Selection

Two authors were contacted,^37,38 one of which provided additional details.³⁷ Upon further review, the Kitagawa³⁷ article was eliminated as fear of movement was determined to be a secondary outcome.

During the data extraction process, 11 articles were removed: 3 articles did not report results using an outcome measure for FA, 3 articles did not address a sudden onset MSK condition, 1 article was a retrospective review of several prior trials, and 4 articles did not treat FA as a primary outcome. The outcome of each round of screenings can be seen in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart (Figure 1), where 22 studies met the selection criteria and were included in the full-text review.

Characteristics of included studies

This review included several patient populations: 1/22 articles featured burn injuries,³⁹ 2/22 featured a WAD,^40,41 6/22 addressed knee-related conditions,^{32,38,42–45} 6/22 addressed back-related conditions,^46–51 2/22 featured chronic ankle instability (CAI) following ankle sprain,^52,53 1/22 featured hip pain following a fall,⁵⁴ 2/22 addressed shoulder-related conditions,^55,56 1/22 involved amputation,⁵⁷ and 1/22 addressed total hip replacement (THR).⁵⁸

In terms of study design, 14 studies were randomized controlled trials^{38–40,42–49,52,55,58}; 4 were single-subject case reports^50,51,54,56; 2 were single-case design^41,53; 1 was pre-post pilot test,⁵⁷ and 1 was an open pilot study.³² Sample size of the RCTs ranged from 12 to 110. The sample size for all the studies ranged from 1 to 110.

The types of interventions were categorized under the following major categories: (1) education, (2) exercise, (3) graded motor imagery (GMI), (4) manual therapy (MT), (5) multimodal—use of education component with exercise program, (6) multimodal—use of education component with MT and exercise program, (7) multimodal—use of exercise and MT, and (8) multimodal—use of interactive gaming console with exercise program. In this review, 31.8% (7/22) of the interventions featured education,^{32,41–44,54,58} 9% (2/22) exercise,^40,57 9% (2/22) GMI,^46,47 4.5% (1/22) MT,⁵⁵ 18.2% (4/22) multimodal—use of education component with exercise program,^38,45,48,49 13.6% (3/22) multimodal—use of education component with MT and exercise program,^50,51,56 9% (2/22) multimodal—use of exercise and MT^52,53 and 4.5% (1/22) multimodal—use of interactive gaming consoles with exercise program.³⁹ Thus, 45.5% (10/22) of studies involved multimodal interventions.

There were 8 studies carried out in the United States,^{32,42,43,51–54,57} 4 in Turkey,^45,47,55,58 2 in Sweden,^40,49 2 in Italy,^44,56 and 1 each in each of the following countries: Finland,⁴⁸ New Zealand,⁵⁰ India,⁴⁶ China,³⁸ Belgium,⁴¹ and Australia.³⁹

Within the FA outcome measures reported in the studies included; 12/22 used a variant of the Tampa Scale of Kinesiophobia (TSK),^{32,38,40–42,44,45,47–49,55,58} and 6/22 the Fear-Avoidance Beliefs Questionnaire (FABQ).^{46,50,51,53,54,56} One study used both the TSK and the FABQ,⁵² 1 study used the TSK in conjunction with the Photographic Series of Sports Activities for Anterior Cruciate Ligament Reconstruction (PHOSA-ACLR),⁴³ 1 study employed a subjective numerical rating scale for fear of falling,⁵⁷ and 1 study used the Pain and Anxiety Symptoms Subscale (PASS).³⁹

Effect of interventions

Education

Seven studies investigated the effect of various educational interventions on FA.^{32,41–44,54,58}

Three studies investigated the effects of video- or virtual-based educational interventions on FA.^42,44,58 An RCT by Brewer et al.⁴² reported that a virtual, interactive multimedia program educating patients scheduled for ACL surgery about their condition and the treatment process resulted in a significant decrease in kinesiophobia after 6 months compared to baseline and a control group. Cetinkaya et al.⁵⁸ reported a significant decrease in kinesiophobia compared to baseline and a control group after receiving a video-assisted discharge education session and info booklet following THR surgery. Similarly, Russo et al.⁴⁴ observed a significant decrease in kinesiophobia compared to baseline and a control group after regularly watching a therapeutic art video promoting self-confidence and providing psychological support.

One case study and a small case series documented the effects of pain neuroscience education (PNE) on FA.^41,54 Romero et al.⁵⁴ found that receiving PNE education sessions involving “Painful Yarns” by Lorimer Mosely resulted in a significant decrease in kinesiophobia for a patient with acute hip pain after a fall. Similarly, Van Oosterwijck et al.⁴¹ reported a significant decrease in kinesiophobia for 6 patients with WAD (Grades I-II) following individualized sessions focusing on pain centralization, stress, pain cognition, and behavior.

Two studies investigated the effects of cognitive-behavioral therapy (CBT) based intervention on FA.^32,43 An open pilot study by Coronado et al.³² demonstrated that telephone-delivered cognitive-behavioral-based physical therapy (CBPT-ACLR) sessions for patients receiving ACL surgery resulted in a significant decrease in kinesiophobia compared to baseline for 5/8 participants. Conversely, an RCT conducted by Baez et al.⁴³ showed a non-significant decrease in kinesiophobia for female patients with a history of ACL repair following education on CBT and graded exposure with the use of graded-exposure exercise techniques.

Exercise

An RCT by Bunketorp et al.⁴⁰ reported significant decreases in FA across patients with WAD. The study included 2 treatment groups; the first received unsupervised home exercises for cervical muscles and physiotherapy counseling; the second received supervised physiotherapy sessions and cervical muscle exercises in a clinic. While both groups demonstrated improvements in FA, the second group’s outcome was significantly greater than the first. Wong et al.⁵⁷ conducted a pre-post pilot test that demonstrated a large treatment effect when the fear of falling of patients with unilateral amputations of mixed etiology and level was evaluated with a subjective measure. The treatment intervention included MT, stretching, stabilization exercises, dynamic balance exercises, and a functional prosthetic training program.

Graded motor imagery

An RCT by Dudhani et al.⁴⁶ with patients who received surgery for lumbar degenerative disks reported clinically significant decreases in kinesiophobia in both the treatment and control groups and significantly greater decreases in the treatment group. In addition to usual care, the treatment group followed the first 2 stages of the GMI protocol⁵⁹; consisting of laterality training via the Recognize App, localization training, in addition to sensory discrimination training, graphesthesia, and 2-point discrimination. The control group was reported to receive no active intervention. Similarly, an RCT conducted by Salik Sengul et al.⁴⁷ for participants who underwent lumbar spinal surgery observed a significant decrease in kinesiophobia compared to the control group, after receiving usual care (exercise program) and performing stage 2 of the GMI protocol at home with the assistance of audio recordings to guide participants through the exercises.⁵⁹

Manual therapy

Coban et al.⁵⁵ conducted an RCT with patients with arthroscopic shoulder repairs who received a 1-time myofascial release session and observed no significant difference in kinesiophobia post-treatment compared to the control group.

Multimodal—use of education component with exercise program

An RCT by Johannson et al.⁴⁹ reported decreases in kinesiophobia overall for a lumbar-disc surgery group who participated in either a supervised clinical program with positive reinforcement of good behavior, encouragement of active coping skills, and personalized modifications to address barriers to exercise, compared to a home program. No significant difference in kinesiophobia was observed between both treatment groups. Ilves et al.⁴⁸ conducted an RCT on patients who have undergone lumbar fusion, who, alongside a standard exercise program, received FA counseling sessions as well as booster sessions to identify and address barriers to exercise. Researchers reported significant improvements in items 1 and 9 of the TSK compared to the control group, as well as significant change over time in item 1 of the TSK in the treatment group. In an RCT conducted by Eymir et al.,⁴⁵ patients with total knee arthroplasty (TKA) in the treatment group demonstrated significant decreases in kinesiophobia compared to baseline and the control group following an intervention consisting of a pre-operative education session about progressive muscle relaxation (PMR) and subsequent PMR exercises. In an RCT conducted by Lu et al.³⁸ for patients with TKA, a greater non-significant decrease in kinesiophobia was observed for participants who received micro-video broadcasting of cognitive belief education and exercise behavior education via WeChat compared to participants who received regular in-person education and exercises from a rehab professional.

Multimodal—use of education component with MT and exercise program

A case report by Brindisino et al.⁵⁶ demonstrated a significant decrease in FA in a patient with a massive rotator cuff tear who refused surgery but received physiotherapy sessions, education about pain neurophysiology and the meaning of rehabilitation, MT, supervised exercises, and an additional home program. Zimney et al.⁵¹ also demonstrated a significant decrease in kinesiophobia in a case report discussing a patient with lumbar strain with right lower extremity radicular pain. The treatment included therapeutic neuroscience education, MT, sensory neuromodulating techniques, and an additional home neurodynamic mobility exercise program. A case report conducted by Toomey et al.⁵⁰ showed a significant decrease in kinesiophobia for a participant following lumbar fusion surgery who received a treatment program consisting of PNE, compound movement exercises, and MT.

Multimodal—use of exercise and MT

Powden et al.⁵³ conducted a single-case study over 4 weeks with a patient with self-reported CAI consisting of 2 components: a supervised component conducted by an athletic trainer performing joint mobilizations, proprioceptive neuromuscular facilitation, strengthening, and balance training; and a home component consisting of muscle strengthening and stretching. The study demonstrated clinically meaningful changes in FA assessed through the FABQ physical activity subscale (FABQ-PA) at 2 weeks and post-intervention for the FABQ work subscale (FABQ-W). In an RCT conducted by Burton et al.,⁵² the authors demonstrated no significant decrease in FA between 2 different treatment groups of patients with CAI. The first group received Maitland grade III joint mobilizations versus the second group who performed repetitive oscillations to mobilize the affected joint.

Multimodal—use of interactive gaming console with exercise program

Parker et al.³⁹ conducted an RCT reporting a decrease in kinesiophobia using the Pain Anxiety Symptoms Scale (PASS) in burn patients with total burn surface of ≤10% following an intervention consisting of physiotherapy-performed accessory mobilization and assisted range-gaining techniques, core stability exercises, and cardiorespiratory training, as well as Wii fit/sports games and instructions to reduce compensatory movement patterns while playing with the console. In contrast, the control group was given the same rehabilitation program without the Wii fit/sports games portion, but no significant difference in the PASS scores, and thus no change in kinesiophobia was observed between groups. This was the only article included in this review that specifically studied burn survivors, further supporting the need to broaden our examination of the literature to studies examining populations with sudden onset acquired MSK conditions.

DISCUSSION

This review sought to investigate the range of evidence-based interventions that are carried out to address FA within the sudden onset MSK condition population. This was undertaken with the goal of identifying interventions for FA that may transfer to the burn survivor population.

Summary of main results and recommendations

Education was the intervention category most commonly employed, whether implemented as the sole intervention or as a part of a multimodal intervention in the majority (14/22) of the included articles.^{32,38,41–45,48–51,54,56,58} These educational approaches were centered around 3 main themes: Informing patients pre- and post-op about surgical procedures and care, reducing patient fear concerning their painful condition, and coaching techniques to promote more active engagement in their rehabilitation or the management of their symptoms.

Pre- and post-op patient education

When patient education is centered around the surgical procedure and aftercare/discharge, the use of multimedia saw higher reductions in-patient FA compared to standardized text and image handouts.^42,58 Indeed, videos are useful to explain to the patient the anatomy of their condition, to offer testimonies of previous patients who have undergone the same injury experience, to detail the post-operative recovery and rehabilitation, as well as to demonstrate ways to resume activities of daily living immediately following surgery (such as with transfers and self-care activities), in addition to printed and online resources.^42,58

However, the success of these approaches does not rest solely on video education pre- and/or post-surgery. In both of the RCTs highlighted above, the use of video and multimedia materials was always accompanied by the presence of a rehabilitation professional who was available to answer questions and clarify concerns or misunderstandings.

For the burn survivor population, the use of video and multimedia education tools should be customized to those activities, occupations or context that patients identify when completing the Burn Survivor Fear-Avoidance Questionnaire.¹⁷ The information will also need to be adjusted based on where the burn survivor is in their recovery profile since treatment recommendations are commonly time-limited or specific. For example, immobilization may be required immediately post-grafting, but once healing has progressed active mobilization is more likely to be emphasized. There are extensive educational resources that are freely available online through organizations such as the Burn Model Systems⁶⁰ or the Phoenix Society,⁶¹ but as emphasized in the evidence summary, having a health care professional present while reviewing these materials optimizes the personal application and contextual nuancing required for individual patients to experience a reduction in their fear avoidant beliefs and behaviors.

Education targeting patient beliefs and behaviors

Education strategies, such as PNE -and CBT-based interventions, that target negative patient beliefs and behaviors had a significant influence on FA.

Pin neuroscience education aims to educate patients on the neurophysiological theory of pain mechanisms in the brain and body to then address and challenge their personal perceptions and relationship with pain.⁴⁷ The successes of the featured PNE interventions in reducing FA were attributed to the fact that patients were able to utilize their new-found awareness of neurophysiological pain mechanisms to deconstruct the false and negative belief that pain is directly related to physical harm and tissue damage.^{41,50,51,54,56} Rather, since they understood that pain acts as a warning signal for what the brain perceives as potential danger, they are able to identify their negative beliefs regarding pain and desensitize their nervous system to decrease pre-emptive pain signals.⁵⁶ Participants shared that as they became more informed on pain mechanisms and their own perceptions of pain, they were able to establish more realistic expectations for their rehabilitation and be more active in their participation.⁵⁴

Cognitive-behavioral therapy-based interventions target negative patient beliefs and behaviors that act as a barrier to activity and rehabilitation through the use of positive reinforcement and various active coping strategies [26]. These strategies included identifying barriers or supports that enable or prevent patients from participating in meaningful activity and rehabilitation,^32,48 techniques to manage fear and pain through on-the-spot breathing techniques or adaptation of the exercise,^32,42,58 and understanding and diminishing catastrophic thoughts related to pain and injury.^32,40,50 Through these approaches, patients were given the opportunity to address psychosocial difficulties and were encouraged and reassured by a professional during their rehabilitation process.^32,45,48,49 Whilst much variability was observed in the implementation of these interventions throughout the review, significant decreases in FA were observed overall.

For the burn survivor population, an increased understanding of the neuroscience associated with their pain experience may decrease their fear reactions when confronted with the presence of an activity that they perceive as threatening. This in turn, may reduce their avoidant behavior encouraging re-engagement in valued life activities as proposed by the FA model.^1,2 The use of CBT-based treatment has already been shown to improve the psychological well-being of burn survivor;⁶² however, the application of this treatment technique to reduce FA in burn survivors requires further investigation.

Grading and exposure

One study included a return-to-work program and featured the unique implementation of one-to-one coaching and work-task simulations supervised by a rehabilitation therapist.⁵⁴ The simulation of work tasks allowed patients to be exposed to their fearful activities in a protected and controlled environment, thus desensitizing their pain- and fear-based reactions to the tasks. They also worked collaboratively with their therapist to implement principles of energy and pain management to decrease their chances of injury during the program and when they return to work.⁵⁴ Their tasks were also modified and graded to allow for personalization of the program in order to promote progressive return to work with lower risks of pain and reinjury. Effectively, occupational therapists are well placed in this context, as a substantial portion of their role consists of grading activities and tasks in order to gradually restore the person’s participation at their own pace.⁶³

The effectiveness of graded-exposure therapy to fear-inducing activities was also observed in a subsequent study.⁴³ Patients were gradually exposed to specific situations that they ranked from least to most fear-eliciting, and they were asked to compare their “expected level of fear” to their “experienced level of fear” for each situation.⁴³ Gradual exposure allowed patients to slowly familiarize and desensitize themselves with each situation at their own pace until they were ready to advance and finally complete the program.⁴³ This resulted in a significant decrease in FA for the patients.

In fact, grading is a therapeutic element that appears in 10/22 of our studies^{40,43,45–51,53} and was associated with a significant decrease in FA in 8/22 of those studies.^{40,43,45–47,50,51,53} Though grading was never explicitly mentioned as having a direct influence on FA, it allows the intervention to be personalized to the patient’s current capacities and progress without inducing further pain or injury.⁶⁴ Patients also create smaller objectives that can continuously motivate the patient as they achieve them gradually, which can have a positive effect on the patient’s psychological state with regards to rehabilitation.⁶⁴ Indeed, this concept appears to match the steps of the positive cycle of recovery that is highlighted in the Vlaeyen model of FA, where grading encourages confrontation of the pain-inducing task in a manageable way, thus promoting recovery by decreasing FA.⁶⁵ Thus, further research directly examining the impact of grading on FA with burn survivors is recommended.

Educational interventions that did not result in significant reductions in FA

Studies where the educational component was only implemented in the late post-op period (3 weeks to 3 months) did not result in a significant change in FA.^48,49 This suggests that patient education should ideally commence as soon as possible to observe an improvement in FA.

Very short-term interventions, such as Lu et al.,³⁸ which ran over the course of 7 days, did not yield significant results but demonstrated a tendency towards a decrease in FA. Therefore, more research with a longer timeframe for the micro-video broadcasting interventions is recommended to evaluate its true effects on FA.

Graded motor imagery

Both RCTs studying the effects of GMI reported a significant decrease in FA. The benefits of GMI in decreasing FA appears to be due to the visualization of exercises prior to performing them, which does not trigger the protective response to pain, thereby altering the patient’s pain perception.⁴⁶ Thus, visualizing movements without experiencing pain can separate the association of movement with pain, which yields a greater decrease in FA compared to standard care.^46,47

For the burn survivor population, this approach may be a particularly advantageous intervention during the acute phase when certain activities or movements cannot yet be performed such as when tendons are exposed, post-grafting when immobilization is required or for activities that cannot be performed in the hospital setting. However, further research is required.

Exercise interventions

Exercise as a treatment intervention was employed in numerous studies. However, exercise alone was observed to not be an effective intervention in decreasing FA.⁵² This can be explained by the fact that exercise only addresses physical factors, such as range of motion or strength, but does not address psychosocial factors associated with FA.

Four studies documented the effects of multimodal interventions, combining an exercise program with an education component, with significant decreases in observed FA, suggesting that education is the main component that is effective in addressing FA. However, a combination of both may yield even more substantial results, as both physical and psychosocial factors are addressed simultaneously to encourage a more complete recovery.^{40,45,48,49,53}

Manual therapy

Two studies examining MT interventions reported no significant change in FA.^52,55 Thus, similar to exercise, MT alone has been shown to be ineffective in decreasing FA, since the goal of MT was to directly address the participants’ physical pain, which does not necessarily affect FA as it is more of a psychological phenomenon.⁵⁵ MT interventions paired with exercise were also seen to have a low impact on participants’ fear of falling, further emphasizing that both of these interventions are ineffective in addressing FA.⁵⁷

However, 3 case studies reported on multimodal interventions that combined education with exercise and MT and observed a significant decrease on FA.^50,51,56 These studies suggest that the educational component aims to enhance patients’ understanding of pain mechanisms while addressing and challenging negative beliefs about pain that can hinder their participation in rehabilitation. The exercise component focuses on strengthening the body, and the MT component provides a physical demonstration of the patients’ musculoskeletal capacities, helping them test the physical expectations of their body.^50,51

Console games

One RCT determined that the use of interactive gaming consoles to play sports games was not effective in decreasing FA compared to an exercise program.³⁹

The interplay between FA/disability/pain

The FA model of pain describes the interlinking of 3 components—pain, FA, and negative affect.² To reiterate, the onset of pain from an acquired condition can lead to FA. If beliefs and behaviors are unaddressed and prolonged, they can lead to reduced activity and decreased engagement in daily occupations. For burn survivors, this impact can be observed through the avoidance, negative beliefs or reactions, or reduced participation in multiple activities that may be triggering, such as cooking, going to restaurants, going out under direct sunlight, which can have a substantial negative impact on their occupational performance and quality of life.¹¹ The lack of focus on meaningful activities in turn may lead to negative effects, reinforcing FA and pain, since the belief of incapacity to perform baseline tasks induces avoidant behavior, further deconditioning and increasing perception of pain.

Role of rehabilitation professionals in addressing FA

Through a collaborative, interdisciplinary approach, rehabilitation professionals may cover the physical, psychological, emotional, or social components of their patients. However, according to several studies, the rehabilitation professionals’ own beliefs and attitudes,^66,67 or those of parents,⁶⁸ may alter patients’ relationship with FA. For health care professionals, if they favor a more conservative approach rather than an early active treatment approach, they may unconsciously transmit certain fear- or movement-related beliefs to the patient.^66,67 In the burn care community, there has been a gradual shift toward early mobilization, but this practice has yet to be universally adopted even when there is evidence to support it.^69,70 In addition, community-based therapists who do not have the same level of expertise and competence as therapists in burn centers may take a more conservative approach. Thus, it is important that rehabilitation professionals reflect on the impact of their recommendations since the long-term perpetuation of FA beliefs and behaviors is commonly underappreciated.

Limitations

The main limitation of this study is that only 1 article pertained directly to burn survivors. Another limitation of this review is the omission of articles that have not deliberately stated the population of inquiry. As a result, this review may have excluded articles that did in fact include participants who had sudden onset MSK condition; however, the authors only provided descriptions such as heterogenous treatment groups or community interventions. Excluding such articles may have missed possible treatment interventions. Another limitation of this study is the exclusion of articles that solely involve psychological interventions. This choice was made to ensure that the interventions described could be employed by a broad array of rehabilitation professionals who treat burn survivors suffering from FA. However, psychology-centered treatment plays a crucial role in the recovery of patients suffering from FA. This review therefore may have omitted psychology-based interventions for FA that would still be relevant for this patient population. Lastly, another limitation of this review is the number of case reports that were included, which may limit the level of evidence.

Future research recommendations

Systematic evaluation of the treatment interventions explored in this review, separately or in combination, is required to determine whether they are effective in reducing FA and disability in burn survivors. The efficacy of treatment interventions to address FA in-patient who sustained sudden onset MSK conditions was examined in this review, since this is the closest patient population to burn survivors, however, further research is required.

CONCLUSION

This scoping review summarized and synthesized the current literature exploring rehabilitation treatment interventions to address FA for sudden onset MSK conditions, such as the burn survivor population. This review supports investigating the impact of incorporating the following interventions into clinical practice with burn survivors, including systematic documentation of FA outcomes:

• The use of multimedia-based education to comprehensively disseminate relevant information regarding the neuroscience of pain, which is customized to the patients’ situation, condition, and treatment.

• The implementation and continuous use of active coping skills, identification of personal barriers to rehabilitation, and promotion of self-efficacy throughout the rehabilitation program.

• The use of grading for activities, exercises, or tasks to allow the patient to progress with minimal pain in order to promote their participation and re-engagement in valued activities.

• The use of GMI, specifically phase 2 (visualization).

• The use of supervised and/or at-home exercise programs, consisting of stretching and strengthening, in combination with an education component.

Appendix 1: Ovid MEDLINE(R) ALL <1946 to November 11, 2022>

• 1 exp Occupational Therapy/ or Occupational Therapists/ or occupational therap*.mp.22 938

• 2 Physical Therapists/ or exp Physical Therapy Modalities/ or physical therap*.mp.194 017

• 3 physiotherap*.mp.32 736

• 4 Rehabilitation/ or rehabilitation.mp.357 412

• 5 exercise therapy.mp. or Exercise Therapy/49 778

• 6 1 or 2 or 3 or 4 or 5526 561

• 7 Low Back Pain/ or Pelvic Girdle Pain/ or Complex Regional Pain Syndromes/ or Shoulder Pain/ or Back Pain/ or Acute Pain/ or Abdominal Pain/ or Myofascial Pain Syndromes/ or Nociceptive Pain/ or Visceral Pain/ or Pelvic Pain/ or Chronic Pain/ or Flank Pain/ or Breakthrough Pain/ or Facial Pain/ or Musculoskeletal Pain/ or exp Pain/ or Neck Pain/ or Eye Pain/ or Cancer Pain/ or pain.mp. or Patellofemoral Pain Syndrome/ or Chest Pain/918 848

• 8 fear.mp. or Fear/93 916

• 9 7 and 89653

• 10 fear avoidance.mp.1585

• 11 avoidance.mp.90426

• 12 kinesiophobia.mp.1351

• 13 apprehension.mp.3369

• 14 movement avoidance.mp.11

• 15 movement-related fear.mp.4

• 16 avoidance behavio*.mp.5219

• 17 fear of pain.mp.1365

• 18 pain avoidance.mp.179

• 19 pain related anxiety.mp.262

• 20 fear of injury.mp.150

• 21 fear of movement.mp.699

• 22 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21102 362

• 23 6 and 223757

Funding

Open access funding was provided by McGill University.

Conflict of interest statement

The authors report there are no competing interests to declare.