Graded Activity for Low Back Pain in Occupational Health Care

A Randomized, Controlled Trial

  1. J. Bart Staal, PT, PhD;
  2. Hynek Hlobil, MD;
  3. Jos W.R. Twisk, PhD;
  4. Tjabe Smid, PhD;
  5. Albère J.A. Köke, PT, MSc; and
  6. Willem van Mechelen, MD, PhD
  1. From the Institute for Research in Extramural Medicine and the Department of Social Medicine, VU University Medical Center, Amsterdam, the Netherlands; KLM Health, Safety and Environment, Schiphol, the Netherlands; University Hospital Maastricht, Maastricht, the Netherlands; and Body@Work Research Center on Physical Activity, Work and Health TNO VUmc, Amsterdam, the Netherlands.

    Abstract

    Background: Low back pain is a common medical and social problem frequently associated with disability and absence from work. However, data on effective return to work after interventions for low back pain are scarce.

    Objective: To determine the effectiveness of a behavior-oriented graded activity program compared with usual care.

    Design: Randomized, controlled trial.

    Setting: Occupational health services department of an airline company in the Netherlands.

    Patients: 134 workers who were absent from work because of low back pain were randomly assigned to either graded activity (n = 67) or usual care (n = 67).

    Intervention: Graded activity, a physical exercise program based on operant-conditioning behavioral principles, to stimulate a rapid return to work.

    Measurements: Outcomes were the number of days of absence from work because of low back pain, functional status (Roland Disability Questionnaire), and severity of pain (11-point numerical scale).

    Results: The median number of days of absence from work over 6 months of follow-up was 58 days in the graded activity group and 87 days in the usual care group. From randomization onward, graded activity was effective after 50 days of absence from work (hazard ratio, 1.9 [95% CI, 1.2 to 3.2]; P = 0.009). The graded activity group was more effective in improving functional status and pain than the usual care group. The effects, however, were small and not statistically significant.

    Conclusions: Graded activity was more effective than usual care in reducing the number of days of absence from work because of low back pain.

    Article and Author Information

    • Acknowledgments: The authors thank the many people who contributed to this study and especially the workers who participated; the staff and participating occupational health physicians of KLM Arbo Services; and physiotherapists Michel Punte, Koen Zoetelief, and Ineke Draisma for providing the graded activity treatment.

    • Grant Support: By the Dutch Health Insurance Executive Council (CVZ), grant DPZ 169/0.

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: Willem van Mechelen, MD, PhD, Department of Social Medicine and EMGO Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands; e-mail, W.vanMechelen{at}vumc.nl.

    • Current Author Addresses: Dr. Staal: Department of Epidemiology, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands.

    • Drs. Hlobil and Smid: KLM Health, Safety and Environment, PO Box 7700, 1117 ZL, Luchthaven Schiphol, the Netherlands.

    • Mr. Köke: Rehabilitation Center Hoensbroeck, PO Box 88, 6430 AB, Hoensbroek, the Netherlands.

    • Dr. Twisk: Department of Clinical Epidemiology and Biostatistics, Institute for Research in Extramural Medicine, VU University Medical Center, van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands.

    • Author Contributions: Conception and design: J.B. Staal, H. Hlobil, T. Smid, A.J.A. Köke, W. van Mechelen.

    • Analysis and interpretation of the data: J.B. Staal, H. Hlobil, J.W.R. Twisk, T. Smid, W. van Mechelen.

    • Drafting of the article: J.B. Staal, H. Hlobil, W. van Mechelen.

    • Critical revision of the article for important intellectual content: J.B. Staal, H. Hlobil, J.W.R. Twisk, T. Smid, A.J.A. Köke, W. van Mechelen.

    • Final approval of the article: J.B. Staal, H. Hlobil, J.W.R. Twisk, T. Smid, A.J.A. Köke, W. van Mechelen.

    • Provision of study materials or patients: H. Hlobil.

    • Statistical expertise: J.W.R. Twisk.

    • Obtaining of funding: W. van Mechelen.

    • Administrative, technical, or logistic support: J.B. Staal, H. Hlobil, W. van Mechelen.

    • Collection and assembly of data: J.B. Staal, H. Hlobil.

    Summary for Patients

    • Summaries for Patients:A Graded Activity Program for Workers with Disabling Low Back Pain Ann Intern Med January 20, 2004 140:I-24
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    1. Ann Intern Med January 20, 2004 vol. 140 no. 2 77-84
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