Physiotherapy-provided operant conditioning in the management of low back pain disability: A systematic review.

BACKGROUND AND PURPOSE: Non-specific low back pain (LBP) is a leading cause of disability in developed countries. Behavioural interventions have been found efficacious in reducing disability in LBP. Operant conditioning is one type of behavioural intervention being employed by physiotherapists; however, the effectiveness of physiotherapist-provided operant conditioning (POC) in the management of LBP disability is unknown. This review aims to answer the question: is POC more effective than comparison interventions in reducing LBP disability? METHOD: A systematic review of randomized controlled trials was conducted using a qualitative analysis of effect. Participants were adults ≥18 years with non-specific LBP. The intervention was defined as a time contingent, graduated increase in activity including goal setting and the education and reinforcement of positive pain behaviours with the aim of decreasing disability. The primary outcome measure was back pain specific disability. Secondary outcomes included generic functional status, pain intensity, sick leave, fear avoidance beliefs or behaviour and adverse effects. RESULTS: Fifteen trials involving 3737 people were included. Eight studies reported a clinically significant difference. The POC intervention was not found to be inferior to any of the comparison interventions in reducing disability. Moderate evidence was found that POC is more effective than other behavioural interventions in reducing long term disability in chronic LBP. Moderate evidence showed POC may be more effective than other treatments in reducing post-treatment fear avoidance beliefs in a sub-acute population but less effective in reducing short term fear avoidance beliefs in a population with mixed LBP. Moderate evidence showed POC is more effective than a placebo intervention in reducing short term pain in sub-acute LBP. CONCLUSION: POC may be considered efficacious in the treatment of LBP. Physiotherapists may also consider POC for its additional effect of reducing long term disability in chronic LBP.