Comparative effectiveness of non-pharmacological interventions on postoperative kinesiophobia in total knee arthroplasty: A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND: Kinesiophobia can hinder recovery after total knee arthroplasty (TKA); however, the comparative effectiveness of various non-pharmacological interventions remains unclear. Through this network meta-analysis (NMA), we aimed to compare and rank these interventions for reducing postoperative kinesiophobia. METHODS: Eight databases were searched from inception to July 20, 2026. Randomized controlled trials (RCTs) evaluating non-pharmacological interventions for kinesiophobia after TKA were included. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Random-effects pairwise meta-analysis and frequentist NMA were performed using standardized mean differences (SMDs) with 95% confidence intervals (CIs). Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation for pairwise comparisons and Confidence in Network Meta-Analysis for the NMA. RESULTS: 71 RCTs involving 6,776 participants were included, comprising 13 network nodes. Ten interventions significantly reduced kinesiophobia compared with usual care. Cognitive behavioral therapy (CBT) showed a significant effect versus usual care (SMD = -2.42, 95% CI: -3.07 to -1.78) and ranked highest according to SUCRA (81.9%), followed by psychological interventions (77.3%), multidisciplinary team interventions (76.8%), and traditional Chinese medicine nursing (73.3%). The certainty of evidence was generally low or very low. CONCLUSION: Current evidence suggests potential benefits of several non-pharmacological interventions, particularly CBT; however, confidence in comparative effects and rankings is limited by risk of bias, small-study effects, heterogeneity, and limited direct comparisons. TRIAL REGISTRATION: Not applicable. REGISTRATION: The protocol was registered in PROSPERO (CRD420251036979).