Effectiveness of Movement Representation Techniques in Chronic Non-Specific Spinal Pain: A Systematic Review and Meta-Analysis

Abstract

Background and Objectives: Movement representation techniques (MRTs), including motor imagery and mirror therapy, have been investigated in several chronic pain conditions; however, their effectiveness in chronic non-specific spinal pain (CNSP) has not been specifically synthesized using meta-analytic methods. This systematic review and meta-analysis aimed to evaluate the effects of MRTs on pain intensity, disability, and kinesiophobia in adults with CNSP. Materials and Methods: A systematic search was conducted in PubMed, CINAHL, Scopus, Cochrane Library, and PEDro, supplemented by grey literature sources. Randomized and non-randomized controlled trials investigating MRTs as a standalone or adjunct intervention in adults with CNSP were eligible. Methodological quality was assessed using the PEDro scale, risk of bias was evaluated using the RoB 2 tool, and certainty of evidence was evaluated using the GRADE approach. Effect sizes were calculated as Hedges' g using a random-effects model. The review was registered in PROSPERO (CRD42023488671). Results: Nine studies involving 411 participants were included in the systematic review, of which eight randomized trials (337 participants) contributed to the meta-analyses. MRTs showed a large and statistically significant effect on pain intensity (Hedges' g = -1.63; 95% CI: -2.56 to -0.70; p = 0.001) and a moderate statistically significant effect on disability (Hedges' g = -0.64; 95% CI: -1.03 to -0.26; p = 0.001). The effect on kinesiophobia was large but not statistically significant (Hedges' g = -1.55; 95% CI: -3.25 to 0.16; p = 0.075). In analyses restricted to motor imagery, significant effects were observed for pain intensity (Hedges' g = -1.87; 95% CI: -2.95 to -0.79) and disability (Hedges' g = -0.75; 95% CI: -1.15 to -0.35), consistent in direction with the primary analyses. Heterogeneity was substantial for pain intensity and kinesiophobia; all pooled trials were judged to be at high risk of bias or to raise some concerns, and the certainty of evidence was very low for all three outcomes. Conclusions: Very low-certainty evidence suggests that MRTs may reduce pain intensity and improve disability in adults with CNSP. Given the high risk of bias and substantial heterogeneity, these estimates are exploratory and do not support firm clinical recommendations. Further well-designed randomized controlled trials with standardized MRT protocols and long-term follow-up are needed.