A systematic review of physical activity correlates in alcohol use disorders.

BACKGROUND: Physical activity might promote mental and physical health in persons with alcohol use disorder. Understanding the barriers and facilitators of participation in physical activity in persons with alcohol use disorder is an essential first step in order to devise effective physical activity interventions. OBJECTIVE: The present review provides a systematic quantitative review of the correlates of physical activity in people with alcohol use disorder. METHODS: Major electronic databases were searched by two independent authors from inception until June 2014. Keywords included 'physical activity' or 'exercise' and 'alcohol dependence' or 'alcohol abuse' or 'alcohol use disorders' or 'alcoholism'. RESULTS: Five papers evaluating 14 correlates were included. Three studies reported that alcohol dependence was unrelated to physical activity behavior, while alcohol abuse showed positive associations in 2 studies. No demographic variable was related with physical activity participation. Functional impairments and distress associated with alcohol use disorders including increased smoking rates, obesity, anxiety, depression and a lower self-efficacy may limit one's ability to be physically active. Data on social, environmental and policy related factors are currently lacking. No included study assessed physical activity levels utilizing objective measurements (e.g. pedometers, accelerometers). CONCLUSION: Although the literature on physical activity correlates in persons with alcohol use disorder still is equivocal, our varied findings support the hypothesis that the participation in physical activity by people with alcohol use disorder is determined by a range of complex factors.

Understanding the role of physiotherapists in schizophrenia: an international perspective from members of the International Organisation of Physical Therapists in Mental Health (IOPTMH).

BACKGROUND: Patients with schizophrenia have a drastically increased morbidity and mortality. In non-mental health settings, physiotherapists play an integral role in the management of many of the comorbidities seen in schizophrenia (e.g. cardiovascular disease, diabetes, obesity). However, the role of the physiotherapist is not well understood in the treatment of patients with schizophrenia. AIM: To obtain an international perspective of mental health physiotherapists on their role within the treatment of individuals diagnosed with schizophrenia. METHOD: A cross-sectional survey of members of the International Organisation of Physical Therapists interested in mental health (IOPTMH) was undertaken. Free text responses to open-ended questions were analysed with a thematic analysis. RESULTS: Two themes emerged: (1) physiotherapists stated they are physical health experts in the multidisciplinary team (MDT), bridging the gap between physical and mental health. (2) Physiotherapists are integral in health promotion efforts in patients with schizophrenia encouraging healthier lifestyle choices and higher levels of habitual physical activity. Physiotherapists felt their interventions had a diverse range of positive effects on patient's health and well-being. CONCLUSION: Physiotherapists are integral part of the MDT that have a focused role on promoting the physical health needs of patients who are diagnosed with schizophrenia.

Social anxiety in physical activity participation in patients with mental illness: a cross-sectional multicenter study.

BACKGROUND: Social anxiety (SA) is a frequent comorbid condition in patients with mental illness. However, no data exist regarding SA in physical activity (PA) situations. The aim of the present study was to measure the level of self-reported SA in PA participation in patients with mental illness compared to healthy controls. METHODS: Six hundred ninety-three patients with mental illness and 2,888 controls aged between 18 and 65 years completed the Physical Activity and Sport Anxiety Scale (PASAS). Group and gender differences in PASAS scores were tested by ANOVA and Scheffé's post hoc test. RESULTS: After controlling for gender (P < .05), the patient group (men 40.2 ± 14.4; women 49.2 ± 17) scored higher on the PASAS compared to control group (men 30.6 ± 12.2; women 37.3 ± 13.7). Within both groups, women reported higher levels of SA compared to men. CONCLUSIONS: Our data indicate that patients with mental illness reported higher levels of SA in PA situations compared to healthy control subjects. Health professionals should consider SA when trying to improve outcome and adherence of patients with mental illness to PA interventions.

An impaired health related muscular fitness contributes to a reduced walking capacity in patients with schizophrenia: a cross-sectional study.

BACKGROUND: Patients with schizophrenia report muscle weakness. The relation of this muscle weakness with performing daily life activities such as walking is however not yet studied. The aim of this study was to quantify walking capacity and health related muscular fitness in patients with schizophrenia compared with age-, gender and body mass index (BMI)-matched healthy controls. Secondly, we identified variables that could explain the variability in walking capacity and in health related muscular fitness in patients with schizophrenia. METHODS: A total of 100 patients with schizophrenia and 40 healthy volunteers were initially screened. Eighty patients with schizophrenia (36.8±10.0 years) and the 40 age-, gender- and body mass index (BMI)-matched healthy volunteers (37.1±10.3 years) were finally included. All participants performed a standing broad jump test (SBJ) and a six-minute walk test (6MWT) and filled out the International Physical Activity Questionnaire. Patients additionally had a fasting metabolic laboratory screening and were assessed for psychiatric symptoms. RESULTS: Patients with schizophrenia did have lower 6MWT (17.9%, p<0.001) [effect size (ES)=-1.01] and SBJ (14.1%, p<0.001) (ES=-0.57) scores. Patients were also less physically active (1291.0±1201.8 metabolic equivalent-minutes/week versus 2463.1±1365.3, p<0.001) (ES=-0.91) than controls. Schizophrenia patients with metabolic syndrome (MetS) (35%) had a 23.9% lower (p<0.001) SBJ-score and 22.4% (p<0.001) lower 6MWT-score than those without MetS. In multiple regression analysis, 71.8% of the variance in 6MWT was explained by muscular fitness, BMI, presence of MetS and physical activity participation, while 53.9% of the variance in SBJ-score was explained by age, illness duration, BMI and physical activity participation. CONCLUSIONS: The walking capacity and health-related muscular fitness are impaired in patients with schizophrenia and both should be a major focus in daily clinical practice and future research.

Progressive muscle relaxation in persons with schizophrenia: a systematic review of randomized controlled trials.

OBJECTIVE: The aim of this systematic review was to assess the effectiveness of progressive muscle relaxation on psychological distress and anxiety symptoms and on response/remission for people with schizophrenia. METHODS: Randomized controlled trials were considered if they investigated progressive muscle relaxation in patients with schizophrenia. EMBASE, PsycINFO, PubMed, ISI Web of Science, CINAHL, PEDro and Cochrane Library were searched. The selection of studies, data extraction and quality assessment were performed independently by two reviewers. RESULTS: Three randomized controlled trials involving 146 patients met the inclusion criteria. Progressive muscle relaxation can acutely reduce state anxiety and psychological distress and improve subjective well-being. No studies investigated the evidence for progressive muscle relaxation as an add-on treatment for general psychopathology and for positive or negative symptoms. Also, no studies assessed the value of progressive muscle relaxation in longer-term treatment and for relapse prevention. There were no data to draw any conclusions about progressive muscle relaxation in comparison with other treatment modalities. None of the studies encountered adverse events. Dose-response relationships could not be determined. CONCLUSION: Progressive muscle relaxation might be a useful add-on treatment to reduce state anxiety and psychological distress and improve subjective well-being in persons with schizophrenia.

Diabetes, physical activity participation and exercise capacity in patients with schizophrenia.

AIM: The aim of this study was to determine if in schizophrenia patients the presence of diabetes is associated with lower physical activity participation and lower exercise capacity compared to patients with pre-diabetes and to patients without (pre-) diabetes. METHODS: Schizophrenia patients without (pre-)diabetes (n = 86) were compared with pre-diabetic (n = 10) and diabetic patients (n = 10). Patients were assessed on physical activity participation using the Baecke physical activity questionnaire and on exercise capacity using a 6-min walk test (6MWT). RESULTS: The three groups were similar in age, sex, mean antipsychotic medication dose, negative and depressive symptoms and smoking behavior. Distance achieved on the 6MWT, however, was approximately 15% shorter (P < 0.05) in patients withdiabetes than in patients without (pre-)diabetes (500.3 ± 76.9 m vs 590.7 ± 101.8 m). Patients with diabetes were also significantly less physically active (P < 0.05). No differences between diabetic and pre-diabetic patients were found. Pre-diabetic patients had a higher body mass index (BMI) than non-diabetic patients (30.0 ± 7.3 vs 24.3 ± 4.3, P < 0.05). An interaction effect with BMI for differences in Baecke (F = 29.9, P < 0.001) and 6MWT (F = 13.0, P < 0.001) scores was seen between diabetic and non-diabetic patients on univariate ANCOVA. CONCLUSION: The additive burden of diabetes might place patients with schizophrenia at an even greater risk for functional limitations in daily life.

Missing data in long-term follow-up of patients with eating disorders using the body attitude test.

OBJECTIVE: Incompleteness of data is a major problem within clinical follow-up studies. The aim of present study was to compare different statistical models in the management of follow-up data in patients with eating disorders using the Body Attitude Test. METHOD: A prospective longitudinal investigation with repeated evaluations over fixed time intervals was conducted among 807 female patients with eating disorders using the Body Attitude Test as a dependent-variable. Three types of missing data mechanisms were explored: missing completely at random, missing at random and missing not at random. RESULTS: Multivariate analysis showed that the missing completely at random type of missing data mechanism is less reliable than the missing at random or missing not at random mechanisms. Five years after admission, the body experience of eating disorder patients is less deviant. Compared with normative data, 37% of the eating disorder patients still had a more negative body experience 5 years after admission. DISCUSSION: There is no single correct method for dealing with missing data. Therefore, it is recommended that multiple methods be used under different assumptions of absenteeism.

Concurrent validity of the international physical activity questionnaire in outpatients with bipolar disorder: Comparison with the Sensewear Armband.

The International Physical Activity Questionnaire (IPAQ) is a self-report questionnaire commonly used in mental health care settings to assess physical activity. However, despite its frequent use, its validity has not been investigated in people with bipolar disorder. The aim of this pilot study was to examine the concurrent validity of the energy expenditure recorded with the IPAQ compared with an objective measure, the Sensewear Armband (SWA). Twenty outpatients with bipolar disorder wore a SWA for 8 full consecutive days and subsequently completed the IPAQ. There was a significant correlation between the active (moderate and vigorous physical activity) energy expenditure as assessed with the IPAQ and SWA (minimum 10min bouts). The IPAQ overestimated active energy expenditure and underestimated total energy expenditure from physical activity by almost 40% compared with the SWA. Results demonstrate that the IPAQ should be used with caution as a measure for estimating energy expenditure from physical activity in outpatients with bipolar disorder.

Cardiorespiratory fitness in outpatients with bipolar disorder versus matched controls: An exploratory study.

BACKGROUND: Patients with bipolar disorder (BD) are approximately twice as likely to die prematurely due cardiovascular diseases (CVD) than the general population. Cardiorespiratory fitness (CRF) is an important health outcome measure, predictive for CVD and premature mortality. AIMS: The aim of the current study was to compare the CRF of outpatients with BD versus age-, gender-, and body mass index (BMI)-matched healthy controls (HC). A secondary aim was to assess potential correlates of CRF. METHODS: All participants underwent a maximal incremental exercise test to measure the maximum oxygen uptake (VO2max, the golden standard assessment of cardiorespiratory fitness), wore a Body Sensewear Armband for 5 subsequent days to assess their physical activity behavior and completed the Positive-and-Negative-Affect-Schedule (PANAS). RESULTS: Outpatients with BD (n=20; 47.8±7.6years) had a significantly lower VO2max compared with HC (n=20; 47.8±7.6years) (26.0±7.3 versus 30.4±6.5ml/min/kg, P=0.047). A higher VO2max was correlated with younger age, higher active energy expenditure, higher PANAS positive and lower PANAS negative affect scores and a lower antipsychotic medication dose. LIMITATIONS: The limited sample and cross-sectional design preclude definitive conclusions. CONCLUSIONS: Compared with HC, outpatients with BD have reduced CRF levels of approximately 4.4ml/min/kg. In the general population such reductions are associated with a 20% increased premature mortality risk. Interventions targeting CRF in BD are required. Although more research is needed, clinicians should consider the utility of objective assessments of CRF for risk stratification in outpatient settings.

Validity of the 6min walk test in outpatients with bipolar disorder.

Cardiorespiratory fitness is a major modifiable risk factor for cardiovascular diseases. People with bipolar disorder have a reduced cardiorespiratory fitness and its assessment within a multidisciplinary treatment therefore is necessary. We investigated the validity of the 6min walk test in people with bipolar disorder. A secondary aim was to assess clinical and demographic characteristics that might interfere with cardiorespiratory fitness performance. 19 (5♂) outpatients (47.1±8.3 years) underwent a 6min walk test and a maximal cardiopulmonary exercise test on a cycle ergometer and completed the Positive-and-Negative-Affect-Schedule (PANAS) and Beck Depression Inventory (BDI). The distance achieved on the 6min walk test correlated moderately with peak oxygen uptake obtained during the maximal cardiopulmonary exercise test. The variance in age, weight and the PANAS negative score explained 70% of the variance in the distance achieved on the 6min walk test. The 6min walk test can be used as a measure-of-proxy to gauge cardiorespiratory fitness in people with bipolar disorder when maximal cardiopulmonary exercise test equipment is not available. Negative mood should be considered when evaluating the cardiorespiratory fitness of this vulnerable population.

The functional exercise capacity and its correlates in obese treatment-seeking people with binge eating disorder: an exploratory study.

PURPOSE: The primary aim was to compare the functional exercise capacity between obese treatment-seeking people with and without binge eating disorder (BED) and non-obese controls. The secondary aim was to identify clinical variables including eating and physical activity behaviour, physical complaints, psychopathology and physical self-perception variables in obese people with BED that could explain the variability in functional exercise capacity. METHODS: Forty people with BED were compared with 20 age-, gender- and body mass index (BMI)-matched obese persons without BED and 40 age and gender matched non-obese volunteers. A 6-minute walk test (6MWT), the Baecke physical activity questionnaire, the Symptom Checklist-90, the Physical Self-Perception Profile and the Eating Disorder Inventory were administered. Physical complaints before and after the 6MWT were also documented. RESULTS: The distance achieved on the 6MWT was significantly lower in obese participants with BED (512.1 ± 75.8 m versus 682.7 ± 98.4, p < 0.05) compared to non-obese controls. No significant differences were found between obese participants with and without BED. Participants with BED reported significantly (p < 0.05) more musculoskeletal pain and fatigue after the walk test than obese and non-obese controls. A forward stepwise regression analysis demonstrated that sports participation and perceived physical strength explained 41.7% of the variance on the 6MWT in obese participants with BED. CONCLUSION: Physical activity participation, physical self-perception and perceived physical discomfort during walking should be considered when developing rehabilitation programs for obese people with BED. IMPLICATIONS FOR REHABILITATION: Rehabilitation programmes in people with binge eating disorder should incorporate a functional exercise capacity assessment. Clinicians involved in the rehabilitation of people with binge eating disorder should consider depression and lower self-esteem as potential barriers. Clinicians should take into account the frequently observed physical discomfort when developing rehabilitation programmes for people with binge eating disorder.

Metabolic syndrome and lung function in schizophrenia: a pilot study.

This pilot study aimed to explore relationships between metabolic and lung functions in patients with schizophrenia. Eighty patients with schizophrenia (55 ♂; 36.8±10.0 years) underwent a spirometry, were screened for metabolic syndrome (MetS), performed a 6-min walk test (6MWT), and completed the International Physical Activity Questionnaire and the Psychosis evaluation tool for common use by caregivers. Patients with MetS (according to the International Diabetes Federation criteria) (n=28; 35%) had a reduced predicted forced expiratory volume for 1 second (77.4±13.2% versus 87.3±12.1%) and predicted forced vital capacity (75.3±11.1% versus 85.4±11.4%). Significantly more patients with MetS were diagnosed with restrictive lung dysfunction (RLD) (according to the Global Initiative for Chronic Obstructive Lung Disease criteria) (13 versus 8). Schizophrenia patients with RLD (n=21; 26.2%) had a significantly larger waist circumference (90.7±12.5 versus 105.6±14.7 cm), were less physically active (653.6±777.9 versus 1517.9±1248.7 metabolic equivalent min/week) and walked less on the 6MWT (502.6±92.3 versus 612.4±101.2 m) than patients without RLD. The present data suggest that in patients with schizophrenia RLD might be associated with metabolic dysfunctions. Further prospective analyses are required to elucidate the complex interrelationships between lung and metabolic functions in patients with schizophrenia.

Associations between perceived neighbourhood environmental attributes and self-reported sitting time in patients with schizophrenia: a pilot study.

Sitting behaviours may, independent of physical activity behaviours, be a distinct risk factor for multiple adverse health outcomes in patients with schizophrenia. In order to combat sitting behaviours health care providers and policy makers require further understanding of its determinants in this population group. The aim of the present study was to investigate the variance in sitting time explained by a wide range of community design and recreational environmental variables, above and beyond the variance accounted for by demographic variables. One hundred and twenty-three patients (42♀) with schizophrenia (mean age=41.5 ± 12.6 years) were included in the final analysis. The built environment was rated using the Instruments for Assessing Levels of Physical Activity and Fitness environmental questionnaire and sitting time was assessed using the International Physical Activity Questionnaire-short (IPAQ) version. Regression analysis showed that environmental variables were related to sitting time. The body mass index (BMI) and disease stage explained 8.4% of the variance in sitting, while environmental correlates explained an additional 16.8%. Clinical practice guidelines should incorporate strategies targeting changes in sitting behaviours, from encouraging environmental changes to the availability of exercise equipment.

Neurobiological effects of physical exercise in schizophrenia: a systematic review.

PURPOSE: The aim of the present systematic review was to provide a summary of neurobiological effects of physical exercise for people with schizophrenia. METHODS: A systematic review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Searches were conducted up to April 2013 across three databases: Medline, PsycINFO, and Embase. A methodological quality assessment using the Downs and Black Quality Index was carried out with all of the included studies. RESULTS: Of the 654 initial data search results, two studies reported in 3 articles including 48 patients (six women) with schizophrenia, met the eligibility criteria. The methodological quality of each study was high. Data on hippocampal volume changes following physical exercise were conflicting while physical exercise-induced changes in other brain areas were absent. Increases in hippocampal volume following physical exercise were correlated with improvements in aerobic fitness and short-term memory. CONCLUSIONS: Future research is needed to investigate whether brain health in people with schizophrenia is activity-dependent. Additionally, research that considers the neurobiological mechanisms and associated functional outcomes of physical exercise in individuals with schizophrenia is required. IMPLICATIONS FOR REHABILITATION: Understanding the neurobiological effects of physical exercise in patients with schizophrenia may contribute to the development of new rehabilitation strategies. There is currently insufficient evidence to determine if physical exercise has a beneficial influence on the brain health of people with schizophrenia.

Associations between expiratory spirometry parameters and limitations in daily life activities in patients with schizophrenia.

OBJECTIVE: This cross-sectional study considered whether variability in respiratory functioning could explain the variability in walking ability of individuals with schizophrenia taking into account variability in body mass index (BMI), lifestyle factors, psychiatric symptoms, antipsychotic medication use and muscular fitness. METHOD: Eighty patients with schizophrenia and 40 age-, gender- and BMI-matched controls underwent a spirometry and the 6-min walk test (6 MWT) and completed the International Physical Activity Questionnaire. Patients were additionally screened for psychiatric symptoms. RESULTS: Compared to health controls, patients with schizophrenia achieved a lower distance on the 6 MWT (583.6 ± 109.7 m versus 710.6 ± 108.4 m, P<.001) and had a lower forced vital capacity (3.7 ± 1.1 L versus 4.3 ± 0.9 L, P<.001) and forced expiratory volume in 1 s (FEV1) (3.0 ± 1.0 L versus 3.6 ± 0.7 L, P<.001). In multiple regression analysis, 68.1% of the variance in walking distance was explained by FEV1, BMI, muscular fitness and total energy expenditure. CONCLUSION: The respiratory health of patients with schizophrenia should be of concern for clinicians. In addition, future research interventions should seek to investigate the impact of an impaired respiratory health upon individuals with schizophrenia.

The assessment, benefits and delivery of physical activity in people with schizophrenia: a survey of members of the International Organization of Physical Therapists in Mental Health.

BACKGROUND: People with schizophrenia typically die over a decade before members of the general population. Physical activity is a low cost and effective intervention that can have a multitude of beneficial effects on people with schizophrenia. Physical therapists lead in the delivery of physical activity in many of the commonly observed co-morbidities in schizophrenia, yet their role in the delivery of physical activity in patients with schizophrenia remains unclear. OBJECTIVE: This study aimed to establish an international consensus on physical therapists' beliefs, potential benefits and practices in the use of physical activity in schizophrenia. METHOD: All members of the International Organization of Physical Therapists in Mental Health were invited to take part in a cross-sectional online survey. All data were analysed using descriptive statistics and quantitative content and/or thematic analysis. RESULTS: One hundred and fifty-one physical therapists from 31 countries responded. Almost all respondents (92%) felt that physical activity benefited patients with schizophrenia, and 75.2% and 22.5%, respectively, felt that it was very important and important that physical therapists oversee in the delivery of physical activity in psychiatric services. Resultant themes established that physical activity has a plethora of beneficial effects on people with schizophrenia including physical health benefits and biopsychosocial effects such as improved mental health, socialization and quality of life. In addition, participants felt they have the necessary theoretical knowledge and clinical skills required for leading and overseeing physical activity programmes in this complex patient group. CONCLUSION: Physical therapists identified that physical activity has a plethora of benefits for patients with schizophrenia and that they have the necessary knowledge and skills to lead and oversee the successful delivery of physical activity in patients with schizophrenia in clinical practice.

Health related quality of life, physical fitness and physical activity participation in treatment-seeking obese persons with and without binge eating disorder.

This study compared the mental and physical health related quality of life (HRQL) of 40 obese persons with BED with 20 age, gender and body mass index (BMI) matched obese persons without BED and 40 age and gender matched non-obese volunteers. Variables contributing to the variability in HRQL were identified. Participants were asked to fill in the MOS 36-item Short Form Health Survey (SF-36), the Symptoms Checklist-90 (SCL-90), the Baecke questionnaire, the bulimia subscale of the Eating Disorder Inventory and the Body Attitude Test. All participants also performed a 6-minute walk test (6MWT). BED patients showed a significant impaired physical and mental HRQL compared with obese and non-obese control groups. In the BED-group female participants showed a significantly more impaired mental HRQL than male participants (40.0±21.2 versus 66.6±10.1). The distance achieved on the 6MWT (512.1±75.8m) explained 22.5% of the variability in physical HRQL in the obese BED-group while gender and the SCL-90 depression score (39.1±12.2) explained 47.1% of the variability in mental HRQL. The present findings suggest that the treatment of obese individuals with BED might benefit by giving more attention to HRQL, depressive symptoms and physical fitness.

Is the prevalence of metabolic syndrome and metabolic abnormalities increased in early schizophrenia? A comparative meta-analysis of first episode, untreated and treated patients.

UNLABELLED: We aimed to discover whether metabolic complications of schizophrenia (SZ) are present in first episode (FE) and unmedicated (UM) patients, in comparison with patients established on antipsychotic medication (AP). METHOD: A systematic search, critical appraisal, and meta-analysis were conducted of studies to December 2011 using Medline, PsycINFO, Embase and experts. Twenty-six studies examined FE SZ patients (n = 2548) and 19 included UM SZ patients (n = 1325). For comparison we identified 78 publications involving 24 892 medicated patients who had chronic SZ already established on AP. RESULTS: In UM, the overall rate of metabolic syndrome (MetS) was 9.8% using any standardized criteria. Diabetes was found in only 2.1% and hyperglycaemia (>100 mg/dl) in 6.4%. In FE, the overall MetS rate was 9.9%, diabetes was found in only 1.2%, and hyperglycaemia in 8.7%. In UM and FE, the rates of overweight were 26.6%, 22%; hypertriglyceridemia 16.9%, 19.6%; low HDL 20.4%, 21.9%; high blood pressure 24.3%, 30.4%; smoking 40.2%, 46.8%, respectively. In both groups all metabolic components and risk factors were significantly less common in early SZ than in those already established on AP. Waist size, blood pressure and smoking were significantly lower in UM compared with FE. CONCLUSION: There is a significantly lower cardiovascular risk in early SZ than in chronic SZ. Both diabetes and pre-diabetes appear uncommon in the early stages, especially in UM. However, smoking does appear to be elevated early after diagnosis. Clinicians should focus on preventing initial cardiometabolic risk because subsequent reduction in this risk is more difficult to achieve, either through behavioral or pharmacologic interventions.

Can cognitive behavioural therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review.

PURPOSE: The primary purpose was to detect randomized controlled trials investigating cognitive behaviour therapy-based (CBT) treatments applied in acute/sub-acute low back pain (LBP). The secondary purpose was to analyse the methodological properties of the included studies, and to identify theory-based treatment strategies that are applicable for physiotherapists. METHOD: A systematic literature search was conducted using four databases. Risk of bias of included studies was assessed and the methodological properties summarized. In addition, content and treatment theory of detected CBT-based strategies were systematically analysed and classified into three distinctive concepts of CBT: operant, cognitive and respondent treatment. Finally, applicability of treatment strategies in physiotherapy practice was discussed. RESULTS: Eight studies were included in the present systematic review. Half of the studies suffered from high risk of bias, and study characteristics varied in all domains of methodology, particularly in terms of treatment design and outcome measures. Graded activity, an operant treatment approach based on principles of operant conditioning, was identified as a CBT-based strategy with traceable theoretical justification that can be applied by physiotherapists. CONCLUSION: Operant conditioning can be integrated in ambulant physiotherapy practice and is a promising CBT-based strategy for the prevention of chronic LBP.