A Graded Activity Program for Workers with Disabling Low Back Pain

Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.

Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians.

The summary below is from the full report titled "Graded Activity for Low Back Pain in Occupational Health Care. A Randomized, Controlled Trial." It is in the 20 January 2004 issue of Annals of Internal Medicine (volume 140, pages 77-84). The authors are J.B. Staal, H. Hlobil, J.W.R. Twisk, T. Smid, A.J.A. Köke, and W. van Mechelen.

What is the problem and what is known about it so far?

Low back pain is a very common problem. It is a common reason that adults see a physician. Low back pain often goes away after several days or weeks; however, in some persons, low back pain persists for many months and interferes with their ability to function and work. Main goals in treating persistent low back pain are to decrease pain and help people resume normal activities and return to work. Despite clear treatment goals, few proven effective strategies have achieved safe and quick return to work for workers with persistent low back pain.

Why did the researchers do this particular study?

To see whether a graded activity program delivered by physical therapists helps workers with persistent low back pain to return to work more often than does usual care.

Who was studied?

134 airline workers who missed work for at least 4 successive weeks because of low back pain.

How was the study done?

The researchers recruited Dutch airline workers who recently had missed work for several weeks because of nonspecific low back pain. They randomly assigned the workers to receive either a graded activity program or usual care. Physical therapists supervised graded activity in 1-hour sessions twice per week. Graded activity included exercises that imitated tasks at work that were difficult and painful (for example, lifting suitcases). Therapists emphasized that it was safe to move and be physically active despite pain. Therapists and workers negotiated graded quotas for increasing amounts of exercise, and workers proposed their own dates for returning to work. Feedback graphs regularly showed workers their progress in meeting exercise quotas. Occupational physicians delivered usual care, which included advice about the work environment (ergonomics), ways to prevent injuries, and return-to-work schedules. All workers reported their pain and ability to function at 3 and 6 months. Researchers reviewed company records at 6 months to assess numbers of days that workers worked.

What did the researchers find?

During the 6-month follow-up, workers receiving graded activity returned to work more often than did workers receiving usual care. They missed 58 days of work while workers receiving usual care missed 87 days. Workers in both groups reported less pain and improved ability to function.

What were the limitations of the study?

The trial involved only 1 workplace setting, and the follow-up period was only 6 months in duration. Because the trial included only a small number of participants, the researchers could not rule out small but important differences in pain and function with the 2 interventions.

What are the implications of the study?

A graded activity program that emphasized the safety of physical activity despite pain returned workers with low back pain to work more often than did usual care.