The effects of motivational interviewing and mindfulness interventions combined with six weeks of neuromuscular exercises on pain-related neurofeedback, balance, and kinesiophobia in women with knee osteoarthritis: A randomized controlled trial

Chaharmahali, Liana; Gandomi, Farzaneh; Yalfani, Ali; Fazaeli, Alireza

doi:10.22034/27.1.51

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Volume 27, Issue 1 (3-2025)

EBNESINA 2025, 27(1): 51-67

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The effects of motivational interviewing and mindfulness interventions combined with six weeks of neuromuscular exercises on pain-related neurofeedback, balance, and kinesiophobia in women with knee osteoarthritis: A randomized controlled trial

Liana Chaharmahali

, Farzaneh Gandomi ^*

, Ali Yalfani

, Alireza Fazaeli

Sport Injuries and Corrective Exercises Department, Faculty of Physical Education and Sport Sciences, Razi University, Kermanshah, Iran , gandomif@razi.ac.ir

Keywords: osteoarthritis, knee, PNF stretching exercises, mindfulness, Motivational Interviewing

Full-Text [PDF 1918 kb] (128 Downloads) | Abstract (HTML) (550 Views)

Type of Study: Original | Subject: Sub-aquatic Medicine
Received: 2024/09/12 | Revised: 2024/12/7 | Accepted: 2024/12/21 | Published: 2025/04/5

Extended Abstract: (183 Views)

Introduction

Chronic pain in knee osteoarthritis (KOA) induces detrimental changes in the central and peripheral nervous systems, which negatively affect patients’ cognitive status and reduce their psychological and physical well-being [1]. KOA is a serious and concerning condition reported by patients, significantly impairing their ability to walk and perform daily activities due to pain, stiffness, immobility, and knee joint deformity [3]. This often leads to despair, with patients feeling that little can be done to treat the disease. Upon diagnosis, many experience insecurity and helplessness.
One successful approach recently introduced in the treatment of chronic pain is motivational interviewing. This method strengthens the client’s intrinsic motivation and increases their readiness to change their lifestyle, helping to resolve any doubts about adopting healthier behaviors. Originally developed for addiction treatment, motivational interviewing has since been applied to various fields, including musculoskeletal pain, weight loss, and rheumatoid arthritis. Its effectiveness in promoting self-management of treatment has been well established [10-12].
Additionally, cognitive interventions such as mindfulness can be beneficial. Mindfulness complements other treatments by modifying the patient’s sensitivity, reducing focus on negative pain-related ruminations, and alleviating anxiety and fear [13-15]. Introduced by Kabat-Zinn in the 1970s, mindfulness emphasizes three core components: non-judgment, purposeful awareness, and present-moment focus [15]. A meta-analysis demonstrated the effectiveness of mindfulness interventions in improving musculoskeletal pain among the elderly, showing reductions in pain severity and enhancements in patients’ quality of life after completing mindfulness programs [16]. Considering the reported benefits of various individual exercise interventions, this study aimed to investigate the combined effects of neuromuscular exercises with motivational interviewing and mindfulness on pain, balance, kinesiophobia, quality of life (QOL), and gait patterns in KOA patients.

Methods

Sixty patients with KOA provided written informed consent to participate in the study. Participants were randomly assigned to one of three groups (n=20 each): motivational interviewing, mindfulness, and a control group. All groups performed neuromuscular exercises. Of those selected based on study criteria, two from the mindfulness group (due to family issues and long distance from home to training location) and six from the control group (three due to COVID-19, two personal issues, and one due to the death of a child) missed post-test measurements, leaving 52 patients who completed the study. The exercise interventions were conducted over six weeks, with four supervised sessions per week, at a standardized gym facility akin to clinical settings. Psychological support was provided by a male clinical psychologist. All assessments took place at the Sports Rehabilitation Laboratory of Bu Ali Sina University, Hamadan. On day one, patients underwent baseline evaluations in the corrective exercise laboratory. Primary outcomes included pain level (measured via a visual analog scale), while secondary outcomes were QOL (SF-36), kinesiophobia (Tampa Scale), balance (Berg Balance Scale), and gait pattern (Zebris device). Assessments were repeated after six weeks of intervention. Data were analyzed using mixed ANOVA; when pre-test differences were significant, ANCOVA was applied. For pairwise comparisons, Bonferroni adjustments were used, and paired t-tests assessed within-group pre-post changes. All data analysis was performed using SPSS software, version 24, at a significance level of 0.05.

Results

After six weeks of neuromuscular training combined with cognitive-motivational interventions, within-group analyses revealed significant improvements in all studied parameters—pain, balance, kinesiophobia, and gait pattern—across all groups (p < 0.05). However, adjusting for baseline differences showed that the motivational interviewing group experienced significantly greater improvements in pain (p = 0.0001), kinesiophobia (p = 0.02), balance (p = 0.002), and QOL (p = 0.02) compared to both other groups. The mindfulness group also demonstrated superior improvements in QOL compared to the other groups. No significant between-group differences were observed for other variables (p > 0.05).

Discussion and Conclusion

The findings indicate that combining effective psychological interventions—particularly motivational interviewing—with neuromuscular exercise can more effectively manage pain severity in KOA patients. The critical impact of such interventions lies in enhancing patients’ sense of efficacy and physical and mental functioning, which in turn increases their willingness to continue treatment. Motivational interviewing notably improved acceptance and commitment to ongoing therapy by boosting motivation and confidence [30]. Review studies suggest that accepting and adhering to therapeutic approaches can drive positive behavioral changes [31].
Studies on the effectiveness of motivational interviewing indicate that patients who undergo this approach develop a better understanding and acceptance of their chronic condition. As a result, they tend to report their pain more realistically and shift away from catastrophic thinking about pain and illness. They also engage in more responsible exercise and treatment behaviors [10]. Motivational interviewing directly impacts pain management because patients become consciously aware of the strategies they need to follow to reduce their pain.
A study by Lee et al. suggested that mindfulness is not directly related to pain intensity but moderates the effect of pain on stress. This suggests that mindfulness may influence how individuals cope with pain [14]. The key difference in outcomes between the two approaches lies in the motivation and responsible acceptance fostered by motivational interviewing.
Consistent with these findings, other studies show that motivational interviewing enhances patients' self-efficacy in managing their disease. By showing patients images of others who have successfully improved, it cultivates positive and hopeful mental imagery, boosting their willingness to continue treatment. These positive effects have been observed in cases involving weight loss, blood pressure control, and diabetes management [23].
Meanwhile, mindfulness practice promotes parasympathetic activation, resulting in deep muscle relaxation, decreased tension, lower cortisol and stress hormones, and reduced muscle stiffness. These effects ultimately enhance patient satisfaction and QOL [28].
Utilizing mindfulness intervention, including meditation training, mental silence, and staying present in the moment, can help patients break free from their current thoughts and behaviors. This can help disrupt the cycle of negative and false thoughts, which is often associated with stress reduction.

Ethical Considerations

All participants provided written informed consent after receiving thorough explanations about the research procedures, benefits, and potential risks. The study protocol was approved by the Ethics Committee of Razi University of Kermanshah (Ethical Code: IR.RAZI.REC.1400.006) and registered with the Iranian Clinical Trials Center (IRCT20210417050997N1). The research adhered to the principles of the Declaration of Helsinki, with all ethical standards rigorously maintained throughout.

Funding

There is no funding support.

Authors’ Contribution

Authors contributed equally to the conceptualization and writing of the article. All of the authors approved the content of the manuscript and agreed on all aspects of the work.

Conflict of Interest

Authors declared no conflict of interest.

Acknowledgments

The authors sincerely thank the rheumatology physicians, clinical psychologists, study participants, and the head of the Sports Rehabilitation Laboratory for their cooperation and dedication throughout all stages of this research.

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Ethics code: IR.RAZI.REC.1400.006

Clinical trials code: IRCT20210417050997N1

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Chaharmahali L, Gandomi F, Yalfani A, Fazaeli A. The effects of motivational interviewing and mindfulness interventions combined with six weeks of neuromuscular exercises on pain-related neurofeedback, balance, and kinesiophobia in women with knee osteoarthritis: A randomized controlled trial. EBNESINA 2025; 27 (1) :51-67
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