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Am Fam Physician. 2004;69(12):2906-2907

Clinical Question: Can patients with disabling back pain get back to work faster using operant conditioning?

Setting: Outpatient (specialty)

Study Design: Randomized controlled trial (single-blinded)

Synopsis: The researchers conducting this trial used the same principle that Pavlov used to train his dogs: operant conditioning. The goal was not to increase muscle strength or flexibility in patients with back pain, but to show patients that they could function despite their pain. The idea was that pain and our response to it (e.g., physical inactivity, complaints, absence from work) are learned behaviors reinforced by positive rewards. The researchers reasoned that if they could convince patients that activity might hurt, but that the pain does not reflect harm, and also stress that the primary goal is a return to functioning, not removal of the pain, then perhaps they could condition patients to resume normal activities despite the pain.

Researchers studied 134 airline employees (i.e., baggage handlers, maintenance personnel) with disabling back pain who were unable to work for at least four consecutive weeks. To make the researchers’ task more difficult, the study was conducted in the Netherlands, where workers receive full disability pay for up to one year, regardless of the cause of their disability. The patients were assigned randomly, probably using concealed allocation, to usual care or to the intervention, which was called graded activity. Usual care was provided by an occupational physician who used typical back-to-work strategies. The graded activity was conducted by physical therapists who worked with patients twice a week until they returned to work, or up to three months. The goal was to convince patients that nothing was seriously wrong with their backs.

Participants performed aerobic and strengthening exercises with the goal of increasing their performance over time despite the pain. They also performed exercises designed to mimic their activity at work. The amount of exercise was increased gradually, with a final end point that would signify readiness to return to work. At each session, patients were required to perform the exercises regardless of the amount of pain they were experiencing. The patients received praise each time they met their exercise quota.

Patients in the graded-activity group attended an average of 13 treatment sessions. The median total number of days absent from work because of low back pain was 58 days in the graded-activity group and 87 days in the usual-care group. Graded activity did not affect the time to return to work until more than 50 days after randomization, possibly because of the time required for a significant number of treatment sessions to occur. Both groups improved similarly in functional status and level of pain over time.

Bottom Line: Use of an approach to low back pain that focused on conditioning patients to understand that they could function normally despite the presence of back pain helped patients return to work faster than treatment with usual care (58 days versus 87 days). The intervention is time-intensive and may not always be practical, but it supports the idea that attitude is everything in patients with disabling chronic low back pain. (Level of Evidence: 1c)

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see

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Copyright © 2004 by the American Academy of Family Physicians.

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