Graded activity program for back pain speeds return to work

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Rheumawire

Jan 19, 2004

Graded activity program for back pain speeds return to work

Amsterdam, the Netherlands - A new randomized study has shown that a

graded activity program for low back pain reduced the number of days

that sufferers were absent from work when compared with those who

received " usual care. "

" The graded activity intervention in this study was aimed at changing

the way disabled workers perceive and cope with their back pain . . .

with the message that hurt does not mean harm, " explain Dr J Bart Staal

(University Medical Center, Amsterdam, the Netherlands) and colleagues

in their paper in the January 20, 2004 issue of ls of Internal

Medicine [1].

In an accompanying editorial [2], Dr Weinstein

(Dartmouth-Hitchcock Medical Center, Lebanon, NH) says this study " is

important because it represents research into treatments that may help

reduce the economic and societal costs of low back pain. "

The study involved 134 workers employed by KLM Royal Dutch Airlines at

Schiphol Airport in Amsterdam in a variety of roles, including baggage

handlers, engineering and maintenance staff, and cabin crew. All had

been partially or fully absent from work for at least 4 weeks with

nonspecific low back pain.

Half were randomized to the graded activity program, which involved

1-hour exercise sessions with trained physiotherapists twice a week

until they returned to regular work or until the maximum therapy

duration of 3 months was reached. The other half received " usual care, "

which entailed guidance and advice from the occupational physician and

treatment by their GP according to low back pain guidelines.

For the graded activity program, patients were given a full physical

exam at the beginning to confirm the diagnosis of benign, nonspecific

back pain. " The participants were reassured that despite the annoying

pain, nothing was seriously wrong with their backs, " the researchers

explain. Then the physiotherapists, together with the patients, decided

on a set of general exercises (both aerobic and strengthening) and also

individually tailored exercises that imitated physical tasks at work or

painful activities of daily living. Both sets of exercises had to be

performed in each session, and the patient and therapist together

decided on a gradually increasing quota for each exercise to achieve a

preset goal immediately before the proposed date of full return to work.

The educational message to the patients was, " pain does hurt but this

does not mean it harms, [and] exercise and physical activity are

recommended and safe, despite pain symptoms, " Staal et al note.

The median number of days of absence from work over 6 months of

follow-up was 58 days in the graded-activity group, compared with 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;

p=0.009). " The apparent delayed effect may relate to the time involved

in the intervention (on average 13 treatment sessions twice per week)

because participants might be less inclined to return to work during the

active treatment periods, " the researchers comment. The graded-activity

group was also more effective in improving functional status and pain

than the usual-care group, but the effects were small and not

statistically significant.

" We found that graded activity for low back pain in an

occupational-health setting had a beneficial effect on absence from

work, " the researchers comment. The reduction in days of absence from

work because of this intervention " is promising " and confirms results of

an earlier Swedish trial [3,4], they add.

Staal et al say that, in general, disabled workers' return to work

depends not only on their medical condition but also on other factors,

such as compensation, legal issues, and the " workplace culture. " In the

Netherlands, for example, workers usually receive their full salary

during the first year of absence from work, regardless of the cause of

their disability.

The goal of the graded activity program " was to convince workers that

their pain was benign by telling them that it was safe to return to work

and by giving them . . . physical exercise and resumption of work

activities that supported that message. "

The change seen in workers' perceptions of their medical condition and

subsequent return to work was relatively independent of the

circumstances surrounding their working environment, suggesting that the

results " may be generalizable across several settings, " the researchers

say.

Weinstein takes up this point in his editorial. Despite variations in

" workplace culture, " the magnitude of the problem and the lack of

effective treatments are " astonishingly similar in countries with

different cultures about work-related injury, " he states. This new study

" addresses the evidence that psychosocial factors are major predictors

of work absence in low back pain. "

Weinstein says the study has " many strengths [but also] several

shortcomings. " Nevertheless, " allowing the patients to set their

return-to-work date is unique to the Dutch study and empowering, " he

comments.

He wonders, however, whether the treatment effect is maintained beyond

the 6 months of follow-up of the study and whether the

graded-exercise-group employees stayed at the same job at the same level

of performance or whether they had recurrences and had to switch to

lighter duties.

The message of this program is that one can have pain and still

function, he notes, adding that athletes demonstrate this point well.

The difference between an injured athlete and an injured worker is that

the athlete is highly motivated, has high self-esteem, and is not

depressed. " Can we imbue the injured worker with some of the ideals and

motivation of the injured athlete? " he wonders.

" While we should congratulate Staal and colleagues on their successful

intervention, we need to know much more about back pain if we are to

devise more powerful treatments, " Weinstein concludes. " As we wait for

research to increase our understanding, we should avoid harmful

interventions but also tell our patients that 'hurt doesn't mean harm.' "

Nainggolan

Sources

1. Staal JB, Hlobil H, Twisk J et al. Graded activity for low back pain

in occupational health care. A randomized controlled trial. Ann Intern

Med 2004; 140:77-84.

2. Weinstein J. Absent from work: nature versus nurture. Ann Intern Med

2004; 140:142-143.

3. Staal JB, Hlobil H, van Tulder MW, et al. Occupational health

guidelines for the management of low back pain: an international

comparison. Occup Environ Med 2003 Sep; 60(9):618-26.

4. Lindstrom I, Ohlund C, Nachemson A. Physical performance, pain, pain

behavior and subjective disability in patients with subacute low back

pain. Scand J Rehabil Med 1995 Sep; 27(3):153-60.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org