The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

Graded Activity for Low Back Pain in Occupational Health Care: A Randomized, Controlled Trial

J. Bart Staal, PT, PhD; Hynek Hlobil, MD; Jos W.R. Twisk, PhD; Tjabe Smid, PhD; Albère J.A. Köke, PT, MSc; and Willem van Mechelen, MD, PhD
[+] Article, Author, and Disclosure Information

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.

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@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.

Ann Intern Med. 2004;140(2):77-84. doi:10.7326/0003-4819-140-2-200401200-00007
Text Size: A A A

From April 1999 to January 2001, the occupational physicians referred 150 workers. Sixteen workers did not meet the inclusion criteria (Figure 2). A total of 134 participants were randomly assigned to either the graded activity group (n= 67) or the usual care group (n= 67). Data on the number of days of absence from work were available for all randomly assigned participants since work-loss data were available regardless of the worker's participation in treatment or follow-up. Thirteen participants withdrew from the study during follow-up and did not complete the functional status and pain measurements. Except for the cases already mentioned and several incidental missing values for some variables, the data set for the entire follow-up period was complete. Of the 13 participants who withdrew from the study, only 3 did not adhere to the graded activity intervention protocol. One nonadherent participant withdrew from the study immediately after randomization, declining to participate in the graded activity intervention. The 2 other participants were dissatisfied with the content of the graded activity sessions and withdrew after a few sessions.

First Page Preview

View Large
First page PDF preview


Grahic Jump Location
Figure 1.
Example of a graded activity exercise scheme for an exercise consisting of lifting and moving a suitcase with a certain number of repetitions.

During the first 3 sessions, maximal performance of exercises is evaluated. Session 14 marks the participants' return to full regular work.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Flow diagram showing the progress of the participants through the phases of the trial.
Grahic Jump Location




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Submit a Comment/Letter

Summary for Patients

A Graded Activity Program for Workers with Disabling Low Back Pain

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.


Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.