Treatment interventions and assessment of fear-avoidance for chronic musculoskeletal pain: a systematic review protocol

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Abstract Introduction The Fear-Avoidance (FA) model aims to explain how an acute pain experience can develop into a persistent state. The FA model considers five core components: kinesiophobia, pain-related fear, catastrophisation, victimisation, and interpersonal social environment. Amongst these, kinesiophobia, tends to dominate the literature on chronic musculoskeletal pain. As a result, current reviews have not considered the other core components of the FA model when exploring its interventions. Moreover, several synonyms of the term kinesiophobia is not reflected in their search strategies. Coupled with the preference of particular study designs and outcome measures, this systematic review aims to provide and characterise an overview of treatment interventions that consider all study designs, relevant outcome measures, FA components, and FA component synonyms. Methods and analysis Eligible studies will be in English or with an available English translation from 1970 onwards. Databases to be searched include Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, The Allied and Complementary Database (AMED), PEDro, Web of Science, and grey literature. We will include studies involving participants ≥18 years old with chronic musculoskeletal pain, and interventions targeting FA and/or its components. Three review authors will independently screen papers using preestablished eligibility criteria and conduct assessments of risk of bias, with a fourth independent researcher employed to resolve disagreements where found. Qualitative synthesis techniques will be used to characterise the interventions. Patient and Public Involvement (PPI) has been utilised to develop this protocol and will be conducted following completion of the systematic review to discuss and reflect on the findings. Ethics and dissemination This systematic review does not require ethical approval as existing data will be used and the PPI to be conducted is an involvement activity rather than study data. The results will be disseminated through a peer-reviewed journal and via national and international conferences. Prospero registration number [this protocol will be registered following peer review]. Strengths and limitations of this study This systematic review provides a meaningful and patient-centred search in the context of fear-avoidance (FA), as the search strategy purposively includes additional components of FA and its synonyms. The search strategy will include eight relevant measures and all study designs to provide a diverse overview of the current interventions for FA in chronic musculoskeletal conditions. Utilising a combination of established qualitative methods to identify and characterise interventions for fear avoidance and integrating them with the opinions of the PPI community collaborators to better appreciate multiple perspectives and inform further research. A meta-analysis is not considered due to the methodological heterogeneity of including all study designs, however it is not entirely applicable to the scoping objective of this systematic review. The inclusion of participants with comorbidities increases generalisability of results at the risk of introducing additional biases and confounders.

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