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The effectiveness of graded activity for low back pain in occupational healthcare
  1. I A Steenstra1,
  2. J R Anema2,3,5,
  3. P M Bongers2,4,5,
  4. H C W de Vet2,
  5. D L Knol6,
  6. W van Mechelen2,3,5
  1. 1Coronel Institute for Occupational and Environmental Health, Academic Medical Center University of Amsterdam, Amsterdam, the Netherlands
  2. 2Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, the Netherlands
  3. 3Department of Social Medicine VU University Medical Center, Amsterdam, the Netherlands
  4. 4TNO Work and Employment, Amsterdam, the Netherlands
  5. 5Body@Work, Research Center Physical Activity, Work and Health, TNO-VU University Medical Center, Amsterdam, the Netherlands
  6. 6Department of Clinical Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands
  1. Correspondence to:
 Dr P M Bongers
 van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands; paulien.bongers{at}


Background: Low back pain is a common medical and social problem associated with disability and absence from work. Knowledge on effective return to work (RTW) interventions is scarce.

Objective: To determine the effectiveness of graded activity as part of a multistage RTW programme.

Design: Randomised controlled trial.

Setting: Occupational healthcare.

Subjects: 112 workers absent from work for more than eight weeks due to low back pain were randomised to either graded activity (n = 55) or usual care (n = 57).

Intervention: Graded activity, a physical exercise programme aimed at RTW based on operant-conditioning behavioural principles.

Main outcome measures: The number of days off work until first RTW for more then 28 days, total number of days on sick leave during follow up, functional status, and severity of pain. Follow up was 26 weeks.

Results: Graded activity prolonged RTW. Median time until RTW was equal to the total number of days on sick leave and was 139 (IQR = 69) days in the graded activity group and 111 (IQR = 76) days in the usual care group (hazard ratio = 0.52, 95% CI 0.32 to 0.86). An interaction between a prior workplace intervention and graded activity, together with a delay in the start of the graded activity intervention, explained most of the delay in RTW (hazard ratio = 0.86, 95% CI 0.40 to 1.84 without prior intervention and 0.39, 95% CI 0.19 to 0.81 with prior intervention). Graded activity did not improve pain or functional status clinically significantly.

Conclusions: Graded activity was not effective for any of the outcome measures. Different interventions combined can lead to a delay in RTW. Delay in referral to graded activity delays RTW. In implementing graded activity special attention should be paid to the structure and process of care.

  • GP, general practitioner
  • OP, occupational physician
  • PT, physiotherapist
  • RCT, randomised controlled trial
  • RTW, return to work
  • low back pain
  • graded activity
  • randomised controlled trial
  • effectiveness
  • cognitive behavioural
  • return-to-work

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  • Published Online First 17 July 2006

  • This study is granted by: the Netherlands Organization for Health Research and Development (Zon/Mw), Dutch Ministries of Health, Welfare and Sports and of Social Affairs and Employment. The funding organisations had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. International Standard Randomized Controlled Trial Number: 60233560.

  • Competing interests: none.

  • Ivan A Steenstra had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.