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The effectiveness of graded activity in patients with non-specific low-back pain: A systematic review

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Non-specific low-back pain (LBP) is considered a major health and economic problem in Western society. Nowadays a common used intervention on non-specific LBP is graded activity (GA). Graded Activity developed by Lindström et al., consisted of four parts: (i) measurements of functional capacity; (ii) a work-place visit; (iii) back school education and (iv) an individual, sub-maximal, gradually increased exercise program with an operant-conditioning behavioural approach as described by Fordyce et al. To evaluate the effectiveness of GA in adults with non-specific LBP on pain, disabilities and return to work. An extensive literature search of PubMed, Embase, CINAHL and The Cochrane Library was conducted in July 2011. Randomized controlled trials (RCTs) evaluating the effect of GA in patients with non-specific LBP were eligible. Methodological quality of the studies was assessed according to the PEDro scale. A best-evidence synthesis was conducted according to van Peppen et al. to interpret the outcomes of the included studies. Ten articles were included in this systematic review; these articles described five RCTs (680 patients). The best-evidence synthesis revealed that there was no or insufficient evidence for a positive effect of GA on pain, disabilities and return to work in patients with non-specific LBP. Currently there is no or insufficient evidence that GA results in better outcomes of patients with non-specific LBP.
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
Disability & Rehabilitation
2012
34
13
1070
1076
© 2012 Informa UK, Ltd.
10.3109/09638288.2011.631682
0963-8288
1464-5165
Disability & Rehabilitation, 2012; 34(13): 1070–1076
© 2012 Informa UK, Ltd.
ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2011.631682
Background: Non-specific low-back pain (LBP) is considered
a major health and economic problem in Western society.
Nowadays a common used intervention on non-specific LBP is
graded activity (GA). Graded Activity developed by Lindström
et al., consisted of four parts: (i) measurements of functional
capacity; (ii) a work-place visit; (iii) back school education and (iv)
an individual, sub-maximal, gradually increased exercise program
with an operant-conditioning behavioural approach as described
by Fordyce et al. Objective: To evaluate the effectiveness of GA
in adults with non-specific LBP on pain, disabilities and return
to work. Data sources: An extensive literature search of PubMed,
Embase, CINAHL and The Cochrane Library was conducted
in July 2011. Review Methods: Randomized controlled trials
(RCTs) evaluating the effect of GA in patients with non-specific
LBP were eligible. Methodological quality of the studies was
assessed according to the PEDro scale. A best-evidence synthesis
was conducted according to van Peppen et al. to interpret the
outcomes of the included studies. Results: Ten articles were
included in this systematic review; these articles described five
RCTs (680 patients). The best-evidence synthesis revealed that
there was no or insufficient evidence for a positive effect of GA on
pain, disabilities and return to work in patients with non-specific
LBP. Conclusion: Currently there is no or insufficient evidence that
GA results in better outcomes of patients with non-specific LBP.
Keywords: Behavioural graded activity, graded activity,
low-back pain, physiotherapy, systematic review
Introduction
Background
Low-back pain (LBP) is a major health problem and eco-
nomic problem in Western society [1–4]. LBP has impact
on disability, sickness absence and work disability [5]. In
the Netherlands, the point prevalence of LBP was 26.9% in
1998 [1]. Most of the time LBP is benign and self-limiting [6]
and can be considered as non-specic LBP since no specic
musculoskeletal pathology is found [3,4,6,7].
Nowadays a common used intervention on non-specic
LBP is graded activity (GA [8,9]).
e rationale for the GA approach is that disabilities result-
ing from the presence of pain are not only inuenced by muscu-
loskeletal pathology only, but also by patient beliefs, attitudes,
illness behaviour and psychological distress [10]. erefore,
GA is characterized by operant conditioning as described
by Fordyce et al. [11]. Main features of operant conditioning
are: positive reinforcement of healthy behaviour, consequent
withdrawal of attention towards pain behaviour and its time-
contingent instead of pain-contingent management.
GA developed by Lindström [8] consisted of four parts:
(i) measurements of functional capacity; (ii) a work-place
visit; (iii) back school education and (iv) an individual, sub-
maximal, gradually increased exercise program. An operant-
conditioning behavioural approach was applied as described
REVIEW ARTICLE
The effectiveness of graded activity in patients with non-specific
low-back pain: a systematic review
R. N. van der Giessen1, C. M. Speksnijder1,2,3 & P. J. M. Helders1,3
1Department of Physiotherapy Science, Clinical Health Sciences, Utrecht University, Utrecht, The Netherlands, 2Department
of Oral and Maxillofacial Surgery and Special Dental Care, University Medical Center Utrecht, Utrecht, The Netherlands,
and 3Department of Physical Therapy & Exercise Physiology, University Hospital for Children and Youth ‘Het Wilhelmina
Kinderziekenhuis’, University Medical Center Utrecht, Utrecht, The Netherlands
Correspondence: Dr. C. M. Speksnijder, UMC Utrecht, G05.122, P.O. Box 85090, 3508 AB Utrecht. Tel: +31 88 7568040.
E-mail: C.M.Speksnijder@umcutrecht.nl
(Accepted October 2011)
Graded Activity in non-specic low-back pain
Non-specic low-back pain is not only a physical •
problem but can be inuenced by patient’s beliefs,
psychological distress and illness behaviour.
In clinical practise the use of Graded Activity (GA) •
can be recommend when a discrepancy between mus-
culoskeletal functioning and disabilities are present in
a patient, for instance the presence of kinesiophobia.
ere is no or insucient evidence that GA results in •
better outcomes than usual care.
Implications for Rehabilitation
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by Fordyce et al. [11], based on the results of the tests and the
demands from the patients work.
Changing cognitive factors, behavioral factors and physi-
cal activity by GA may result in defeating non-specic LBP.
Physiotherapy generally aims to aect multiple outcome
domains according to the International Classication of
Functioning, Disability and Health (ICF) classication [12].
erefore limitation of bodily function, disability in daily life
and participation have to be studied [12].
In 2001, a systematic review was published with a focus on
behavioural treatments, including GA, in specic and non-
specic chronic LBP [10]. is review concluded that evidence
for GA was limited, but was based upon only one good quality
trial by Lindström et al. [8,13]. Two Cochrane reviews have been
published and evaluated the eectiveness of GA on LBP [14,15].
e review by Ostelo et al. [14] on behavioral treatments for
chronic LBP concluded: GA is more eective than usual care
(UC), for early return to work and reduced long-term sick leave.
e evidence was limited and based upon one trial; furthermore,
this review was strictly focused on patients with chronic LBP.
e second Cochrane review presented the evidence of exercise
therapy treatments for non-specic LBP [15]. is review pro-
vided moderate evidence for the eectiveness of GA on patients
with sub-acute LBP [15]. In recent years, new clinical trials have
been published evaluating the eectiveness of GA. e eec-
tiveness of GA on acute, sub-acute and chronic LBP has not yet
been determined [10,14,15]. us a synopsis of evidence for
GA is missing. To our knowledge, a systematic review about the
eectiveness of GA in patients with acute, sub-acute or chronic
non-specic LBP has not been published. erefore the objec-
tive of this systematic review was to assess the ecacy of GA as
treatment for non-specic acute, sub-acute and chronic LBP in
adults, on pain, disabilities and rate of return to work.
Methodology
Search strategy
A literature search of PubMed (1950 - 17 July 2011), Embase
(<1950 - 17 July 2011) CINAHL (1982 - 17 July 2011) and
e Cochrane Library (1800 - 17 July 2011) was conducted.
For identifying non-specic LBP patients, the medical subject
headings (MeSH) ‘Back Pain and ‘Low-Back Pain’ were used.
A MeSH term for non-specic LBP was absent. Multiple text
words describing GA were used to identify the intervention,
combined with the MeSH ‘Behavior erapy’ and ‘Physical
erapy Modalities. e Boolean word ‘ANDconnected the
intervention and the patient group. A sensitive lter (sensitivity
99.5% and precision 19.3%) was added for identifying random-
ized clinical trials (RCTs [16]). RCTs were included to possibly
obtain higher quality studies. A hand search was added of the
reference lists of the articles found. e highly sensitive search
strategy for retrieval of reports of RCTs was run in conjunc-
tion with a specic search strategy for non-specic LBP, using
patient, intervention, control, outcome (PICO) elements [17].
Selection criteria
All published RCTs into measuring the eect of GA in patients
with non-specic LBP were eligible for inclusion in this
review. No restrictions were applied to any specic language.
Studies should involve adults (age over 18 years). e type
of intervention included had to be GA, behavioural graded
activity (BGA), or operant conditioning in combination with
time-contingent GA.
Selection of studies
Titles of all identied studies were assessed by two reviewers
(one of whom (R.N.G.) is an author) to determine whether
the studies were pertinent to our research question, according
to the inclusion and exclusion criteria. Aer title selection,
the two reviewers assessed the abstracts to determine whether
the selected studies were eligible for this systematic review.
When there was uncertainty regarding the eligibility of the
paper from reading title and abstract, the full text version of
the paper was retrieved and re-evaluated. e full text version
of all papers that met the inclusion criteria were retrieved for
quality assessment and data extraction.
Methodological study quality
e methodological quality of each included study was deter-
mined using the (PEDro) score, that is specically developed
to rate the methodological quality of RCTs evaluating physio-
therapy interventions [18]. e PEDro scale contains 11 items
for internal (criteria 2–9), statistical (criteria 10 and 11) and
external (criterion 1) validity (Tab l e I). Each item is rated yes or
Table I. Methodological quality according to the PEDro scale.
George [35] Lindström [8,13] Smeets [36–38] Staal [31,32] Hlobil [34] Steenstra [33]
Eligibility criteria 1 1 1 1 1
Random allocation 1 1 1 1 1
Concealed allocation 1 1 1 1 1
Baseline comparability 1 1 1 1 0
Blind subject 0 0 0 0 0
Blind clinician 0 0 0 0 0
Blind assessor 1 1 1 1 1
Adequate follow-up 0 1 1 1 1
Intention-to-treat analysis 1 0 1 1 1
Between-group analysis 1 1 1 1 1
Point estimates and variability 1 1 1 1 1
Total score 7/10 7/10 8/10 8/10 7/10
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1072 R. N. van der Giessen et al.
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no. All ‘yes’ scores were summed resulting in a maximum score
of 10 points. e reliability of the PEDro scale is assessed ‘fair’
to good’ (intraclass correlation coecient (ICC) = 0.68 [19]).
Cohen’s κ was determined as an estimate of agreement between
the two assessors for methodological quality of the studies [20].
When indicated, a third independent reviewer was consulted.
Data extraction
A standardized protocol by van Tulder et al. [21] was used for
data extraction.
Qualitative analyses
Pooling of studies was not possible due to the heterogeneity in
interventions applied, control treatments, outcome measures
and follow-up time. erefore, a best-evidence synthesis was
applied. e criteria set out by van Peppen et al. [22] based
on the methodological quality score of the PEDro scale was
used and modied for RCTs only. Consequently, studies were
categorized into ve levels of evidence: strong evidence, mod-
erate evidence, limited evidence, indicative ndings and no or
insucient evidence (Table II).
Results
Search strategy
e specic literature search in the dierent databases revealed
155 citations in total. Removal of duplicates le 103 articles.
When assessed for eligibility, 85 articles were ineligible. Aer
reviewing 18 articles on abstract and full text, eight articles were
excluded as they did not meet the inclusion criteria. Four articles
did not describe GA [23–26], one article focused on economic
aspects of GA [27], one article was a study protocol [28], one
article was not an RCT [29] and one article did describe neck
pain patients [30]. In conclusion, 10 articles were identied that
met our inclusion criteria [8,13,31–38]. e ow diagram of
article retrieval and selection is presented in Figure 1.
Description of studies
e 10 included articles consisted of ve dierent studies: (i)
George et al. [35] reported on one study, (ii) two articles by
Lindström et al. [8,13] were written about the same study,
but reported on dierent outcome measures, (iii) three arti-
cles by Smeets et al. [36–38] were part of a larger study, con-
sisting direct post-treatment results and long-term results,
(iv) three articles by Staal et al. [31,32] and Hlobil et al. [34]
reported on a similar study and (iv) Steenstra et al. [33]
reported on one study. Study characteristics are presented
in Table III.
Table II. Best-evidence synthesis by van Peppen et al. [22].
Level of evidence Criteria
Strong evidence Provided by statistically signicant ndings in outcome measures in
at least two high-quality RCTs, with PEDro scores of at least 4 pointsa
Moderate evidence Provided by statistically signicant ndings in outcome measures in
at least one high-quality RCT and
at least one low-quality RCT (≤ /3 points on PEDro) or one high-quality CCTa
Limited evidence Provided by statistically signicant ndings in outcome measures in
at least one high-quality RCT or
at least two high-quality CCTsa (in the absence of high-quality RCTs)
Indicative ndings Provided by statistically signicant ndings in outcome measures in at least
one high-quality CCT or low-quality RCTsa (in the absence of high-quality RCTs), or
two studies of a non-experimental nature with sucient quality (in absence of RCTs and CCTs)a
No or insucient
evidence
In the case that results of eligible studies do not meet the criteria for one of the above stated levels of evidence, or
in the case of conicting (statistically signicant positive and statistically signicant negative) results among RCTs and CCTs, or
in the case of no eligible studies
aIf the number of studies that show evidence is <50% of the total number of studies found within the same category of methodological quality and study design (RCT, CCT or
non-experimental studies), no evidence will be classied.
Figure 1. Flow diagram of article retrieval and selection. RCT,
randomized clinical trial; LBP, low back pain; GA, graded activity.
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Table III. Summary of study characteristics.
Trial NPopulationaExperimental & Control groupbOutcome Follow-up Author’s conclusion Notes
George
et al. [35]
108 Age: 38 Graded
exposure (GA)
Standard care:
Could contain
exercise,
manipulation,
stabilization.
ODQ, NRS 1 month No dierences in reduction of disability, pain intensity and
physical impairments between groups. (χ2 and ANOVA
statistics)
GA (mean nr.
appointments 5.4
(1.9)).
M/F: 39/69 6 months
Duration: 1–24 weeks (TBC) (mean nr.
appointments 6.2
(2.1)).
LBP with or without radiation,
proximal or distal below the knee.
Lindström
et al. [8]
103 Age: 40 GA UC (concisely
described).
Rate of return to
work.
12 months 1 year results: GA was focused on
return to work with a
workplace visit..
M/F: 71/32 24 months GA returned signicant earlier to work (χ2 4.7 p = 0.03). Log
ratio likelihood ratio test male participant in GA returned to
work signicant earlier than women (χ2 6.1, p= 0.01).
Lindström
et al. [13]
Duration: 6 weeks Average sick
leave.
Patients were industrial blue
collar workers
No power analysis.
2 year results:
An average sick leave duration between groups aer 1 year was a
signicant dierence of p = 0.03 was found in favour of GA with
men. No dierence for return to work was found between groups
for female patients, post intervention and 1 year follow-up.
Smeets
et al. [36]
223 Age: 42 GA Waiting list
controls.
RDQ Post-
treatment
6 month
Post-treatment: GA has a signicant positive eect on pain and
RDQ, (p < 0.01), compared to waiting list controls.
Duration of all
interventions was 10
weeks, 3 times a week.
Smeets
et al. [37]
M/F: 93/79 APT: Group
sessions of
aerobic and
strength.
training
Back Pain 12 months No statistically signicant dierences between APT and GA
were found on any outcome measure (data not presented in
article).
Power analysis was
not intended to be
sucient to compare
APT. versus GA.
Duration: >12 weeks 100-mm VAS
Smeets
et al. [38]
Patients with LBP resulting in
disability (RDQ > 3).
PRI
Staal
et al. [31]
134 Age: 38 GA, 1 hour
sessions two
times a week.
UC Return to work,
sick leave due
to LBP
3 months Number of days absent from work because of LBP: Up to 50
days aer randomization: Hazard ratio was 1.0 (95% CI 0.6 to
1.8; p > 0.2). (p = 0.99).
Aer 50 days: Hazard ratio was 1.9 (95% CI 1.2–3.2; p = 0.009),
in favour of GA.
6 months
M/F: 126/8 12 months
Staal
et al. [32] Duration: 6–13 weeks RDQ
KLM workers with LBP
Hlobil [34] Pain intensity 11
point VAS. RDQ: and pain intensity 11 point VAS. No signicant eects
between groups.
Recurrences of sick leave due to non-specic LBP over the 1
year follow-up period was not statistically signicant (p= 0.75).
Total number of sick days; no statistical dierence between
groups was found (p = 0.38).
Steenstra
et al. [33]
112 Age: 42 GA UC Return to work. 3 months Median time until lasting return to work diered signicant
Kaplan-Meier survival calculation (p < 0.01) between GA
(139 days) and UC (111 days) in favour of the UC group, at 3
months. Aer 6 months a signicant (p = 0.03) eect in favour
of the UC group.
M/F: 43/69 6 months
Duration: >8 weeks Roland-Morris
Disability-24
questionnaire.
LBP (ICD-10 codes: M54.5,
M54.4, M54.3, M54.1, M54.8,
and M54.9)
Pain intensity 10
point VAS. No signicant dierences were found between groups at 3
months or 6 months in pain intensity and disability. Only at 6
months pain improvement was statistically signicant in favour
2–6 weeks sick leave due to LBP
aAge: mean age in years; M/F, Male/Female.
bOnly the distinctive therapies are described.
APT, active physical treatment; GA, graded activity; LBP, low-back pain; ODQ, Oswestry Disability Questionnaire; NRS, Numerical Rating Scale for pain intensity; PRI, pain rating index of the McGill Pain Questionnaire; RDQ, Roland Dis-
ability Questionnaire; UC, usual care, guideline of Dutch College of Occupational Practitioners; VAS, visual analogue scale.
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1074 R. N. van der Giessen et al.
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Population characteristics
Each study included more than 100 patients, to a maximum
of 223. In total, 680 patients participated in these studies
when corrected for overlapping patients. e mean age of
the participants in the included studies was 38–42 years. e
duration of complaints diered between studies from 1 to a
maximum of 24 weeks. e percentage of female participation
in the studies ranged from 5.9% [31,32,34] to 64% [35]. e
study of Lindström et al. [8,13] made an analysis between the
eects of male and female patients.
Study interventions
All studies described a time-contingent management and
reported the use of GA as described in the selection criteria of
this review. Consequently every study used operant condition-
ing, measured functional capacity, provided back school edu-
cational and an individual sub-maximal gradually increasing
exercise programme. e durations and the frequencies of the
GA intervention diered. One hour sessions were provided
two times a week by Staal et al. [31,32,34]. e length of this
programme varied between 6 and 13 weeks. e intervention
by Smeets et al. [36–38] consisted of a 10 week programme
with three sessions a week. Lindström et al. [8,13] did not
set a specic duration or frequencies; the GA treatment was
adjusted to the patients demands and needs [8,13].
e ‘interventions’ given to the control group varied
between the included studies. ese ‘interventions’ con-
sisted of treatment according to guidelines of occupational
medicine in Staal et al. [31,32,34] and Steenstra et al. [33],
an active physical treatment in George et al. [35] and Smeets
et al. [36–38]. Smeets et al. [36–38] also used waiting list con-
trols as a control group (Table III).
Methodological quality
All studies were of good quality according to the PEDro scale
(Table I) [19]. Cohen’s κ was 0.71 and can be considered as
good’ agreement between assessors [20].
Power analysis
George et al. [35] reported that post hoc calculations of
eect sizes indicated that lager sample sizes were required
to detect statistically signicant group dierences. e stud-
ies of Steenstra et al. [33], Staal et al. [32–34] and Smeets
et al. [36–38] mentioned a power analysis, but did not per-
form a power analysis or a post hoc calculation. e study by
Lindström et al. [8,13] study did not mention or calculate a
power analysis.
Qualitative analyses for pain, disabilities and rate of
return to work
George et al. [35], Smeets et al. [36–38], Staal et al. [31,32,34]
and Steenstra et al. [33] reported on the eect of GA on pain
(Table III). George et al. [35]. used a numerical rating scale
and Smeets et al. [36–38], Staal et al. [31,32,34] and Steenstra
et al. [33] used a visual analogue scale (VAS) to measure
pain (Table III). All of these studies, with the exception of
Steenstra [33] reported no statistical signicant dierences
between the control group and GA on the outcome measure
pain. Steenstra’s study [33] reported a signicant dierence at
a 6 months follow-up in favour of the UC control group. In
conclusion, the best-evidence synthesis showed either no or
insucient evidence for the eect of GA on pain in relation
to UC.
George et al. [35], Smeets et al. [36–38], Staal et al. [31,32,34].
and Steenstra et al. [33]. reported on disability due to non-
specic LBP. No statistical signicant dierences were found
between GA and UC. According to the BES, there is no or
insucient evidence for the eect of GA on disabilities.
Lindström et al. [8,13], Staal et al. [31,32,34] and Steenstra
et al. [33] reported on return to work-rate. Lindström et al. [8,13].
reported a signicant dierence (p = 0.03) between the GA
and UC group in favour of GA. However, Steenstra et al. [33].
reported 3 and 6 months statistical signicant ndings (p < 0.01,
p = 0.03) in favour to UC. In addition, Staal et al. [31] reported
a statistical signicant positive eect (p = 0.009) in favour to the
UC group 50 days aer randomization. In conclusion, there is
conicting evidence for the return to work-rate. According to
the BES, there is no or insucient evidence for the eect of GA
on return to work-rate.
Discussion
is systematic literature review presents the found evidence
of the eectiveness of GA in patients with non-specic LBP
when compared to usual care. e best-evidence synthesis
established that there is no or insucient evidence for a posi-
tive eect of GA on pain, disabilities and the return to work-
rate. In this review, 10 articles were included, consisting of ve
dierent RCTs describing the eects of GA [8,13,31–38]. e
included studies were, according to the PEDro scale, of good
methodological quality (Table I). However, some important
comments about the methodological quality can be made. All
studies lacked blinding of participants as well as clinicians.
e studies of Lindström, et al. [8,13], Staal et al. [31,32,34],
Smeets et al. [36–38] did not report power analyses. e stud-
ies of Lindström et al. [8,13], Steenstra et al. [33] and Staal
et al. [31,32,34] did not report the exact UC policy.
e studies diered in study population, administered GA
and UC, as well as in duration of intervention. Consequently,
a meta-analysis could not be performed. erefore the best-
evidence synthesis was a good replacing option [22]. Most
included studies [31–38] used pain as an outcome measure.
is conicts with the rationale of GA. e focus of GA is to
gradually improve activities of patients, so pain is not suit-
able as an outcome measure for the eect of GA. Moreover,
measuring pain may inuence the focus of the patient to pain,
instead of a focus towards function.
Presently, the focus of physiotherapy and occupational
medicine has shied from treating impairments to focus-
sing on function [39–41]. Nowadays, therapies are focussing
on activities and participation according to the ICF [12].
Consequently, during UC, behavioural aspects are most
probably advocated, like a positive reinforcement of healthy
behaviour or a time-contingent management. is could, to
some extent, explain the small dierences between UC and
GA in the included studies.
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Lindström et al. [8,13] showed a statistical signicant
eect of GA for male patients on return to work-rate, but not
a signicant eect for female patients. Other studies reported
no statistical signicant gender dierences between the inter-
vention and control group for pain, disabilities and return to
work-rate [31–38]. In these studies, however, subgroup analy-
ses for gender were not performed.
Other systematic reviews have been published on the eec-
tiveness of GA [10,14,15]. All these reviews present limited
evidence in favour of GA. Our systematic review presents no
or insucient evidence of GA in patients with LBP. is dier-
ence can be claried; our systematic review specically focuses
on a GA intervention. We did not exclude RCT’s based on the
duration (acute, sub-acute and or chronic) of non-specic LBP
in the study populations. e focus of published systematic
reviews was on behavioural treatments in chronic LBP [10,14]
or exercise therapy treatments in sub-acute LBP [15]. For this
reason, we could include more RCT’s. Furthermore, we have
included recently published RCT’s. Hence, the possible dier-
ences in the included RCT’s and thus the outcomes.
e eectiveness of GA has been evaluated by a RCT in
patients aer rst time lumbar disc surgery [42]. is study
reports no statistical dierences between UC and GA on func-
tional status, pain, pain catastrophizing, fear of movement,
range of motion or return to work-rate aer intervention and
aer 1-year-follow up. e results of our study provided the
same results on pain, disabilities and return to work-rate in non-
specic LBP. e authors conclude that treatment principles as
implemented in GA may not apply to this group [42]. We concur,
the inuences of patient beliefs, attitudes, illness behaviour and
psychological distress and musculoskeletal pathology can result
in the presence of pain and disabilities. Our systematic review
could not report whether the study populations had self-limiting
beliefs, attitudes, illness behaviour and or psychological distress,
as these factors were not objectied in the included studies.
Future studies should investigate underlying mechanisms
of behavioural treatment in non-specic LBP patients. It
would be interesting to examine the eect of GA in patients
with objectied self-limiting beliefs, attitudes, illness behav-
iour or psychological distress [10]. Changing cognitive factors,
behavioural factors and physical activity with GA, may result
in defeating non-specic LBP. is would test the rationale for
the GA approach.
In clinical practise, we can recommend to use GA when
a discrepancy between musculoskeletal functioning and dis-
abilities are present in a patient (for instance the presence
of kinesiophobia). If self-limiting inuences from beliefs,
attitudes, illness behaviour and/or psychological distress in
everyday living are present, GA can be used [10]. However,
when implementing GA, it is recommended to use outcome
measures which evaluate the rationale of GA. Measuring per-
formance or disabilities focuses the patient towards function-
ing and not towards pain. e studies included in this review
used the Oswestry Disability Questionnaire, Roland Disability
Questionnaire or the Roland-Morris Disability questionnaire,
but other instruments focusing on functioning can be used.
Further research on instruments measuring performance
or disabilities in relation to GA can be performed.
In conclusion, there is no or insucient evidence that GA
results in better outcomes than UC. Non-specic LBP is not
only a physical problem, but can be inuenced by patient’s
beliefs, psychological distress and illness behaviour. If one or
more of these factors are present within a patient, it can be
recommended to implement GA.
Acknowledgements
e authors would like to thank J.M. Westeneng for selecting
and assessing the methodological quality of the studies and
suggestions. Furthermore our thanks go to E.M. Buining, for
assisting in the literature search.
Declaration of Interest: e authors report no conicts of
interest.
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... In the graded activity, exercise activities are not determined based on pain alone, but by pre-determined activity quotas [10]. Exercise programmes that have used graded activity principles for the management of patients with LBP have reported improvement in patients' health status, specifically reduced disability and reduced workabsenteeism [11][12][13]. Van Der Giessen and colleagues [12] in a systematic review recommended for further studies to substantiate the current evidence for the efficacy of graded activity. Whilst studies suggest the efficacy of graded activity in the management of LBP for the general population, there appears to be a paucity of studies conducted in well-defined LBP populations having other comorbid health problems. ...
... Exercise programmes that have used graded activity principles for the management of patients with LBP have reported improvement in patients' health status, specifically reduced disability and reduced workabsenteeism [11][12][13]. Van Der Giessen and colleagues [12] in a systematic review recommended for further studies to substantiate the current evidence for the efficacy of graded activity. Whilst studies suggest the efficacy of graded activity in the management of LBP for the general population, there appears to be a paucity of studies conducted in well-defined LBP populations having other comorbid health problems. ...
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... This has been highlighted in earlier systematic reviews of the literature. 46,51,80 In the current review, none of the included studies on graded activity showed greater efficacy in improving outcomes compared to standard physical therapy. Second, despite the apparent accessibility and feasibility, internet-based psychological programs provided to patients in physical therapy do not seem to contribute to better outcomes compared to physical therapy alone. ...
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... Interventions including communicative and educative strategies have already been investigated in previous papers focused on the management of CLBP, but a more in-depth view is needed for some issues, namely in respect to the inclusion criteria and outcomes investigated. Earlier systematic reviews exploring the effectiveness of graded activity, graded exposure, reassurance, coaching and health literacy were carried on patients with acute [25], sub-acute [26], mixed LBP [27,28] or CLBP sometimes enrolled in non-randomized controlled trials. [29]. ...
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Background and Purpose. Assessment of the quality of randomized controlled trials (RCTs) is common practice in systematic reviews. However, the reliability of data obtained with most quality assessment scales has not been established. This report describes 2 studies designed to investigate the reliability of data obtained with the Physiotherapy Evidence Database (PEDro) scale developed to rate the quality of RCTs evaluating physical therapist interventions. Method. In the first study, 11 raters independently rated 25 RCTs randomly selected from the PEDro database. In the second study, 2 raters rated 120 RCTs randomly selected from the PEDro database, and disagreements were resolved by a third rater; this generated a set of individual rater and consensus ratings. The process was repeated by independent raters to create a second set of individual and consensus ratings. Reliability of ratings of PEDro scale items was calculated using multirater kappas, and reliability of the total (summed) score was calculated using intraclass correlation coefficients (ICC [1,1]). Results. The kappa value for each of the 11 items ranged from .36 to .80 for individual assessors and from .50 to .79 for consensus ratings generated by groups of 2 or 3 raters. The ICC for the total score was .56 (95% confidence interval=.47–.65) for ratings by individuals, and the ICC for consensus ratings was .68 (95% confidence interval=.57–.76). Discussion and Conclusion. The reliability of ratings of PEDro scale items varied from “fair” to “substantial,” and the reliability of the total PEDro score was “fair” to “good.”
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Study Design. A systematic review of randomized controlled trials. Summary of Background Data. The treatment of chronic low back pain is not primarily focused on removing an underlying organic disease but at the reduction of disability through the modification of environmental contingencies and cognitive processes. Behavioral interventions are commonly used in the treatment of chronic (disabling) low back pain. Objectives. To determine whether behavioral therapy is more effective than reference treatments for chronic nonspecific low back pain and which type of behavioral treatment is most effective. Methods. The authors searched the Medline and PsychLit databases and the Cochrane Controlled Trials Register up to April 1999, and Embase up to September 1999. Also screened were references of identified randomized trials and relevant systematic reviews. Methodologic quality assessment and data extraction were performed independently by two reviewers. The magnitude of effect was assessed by computing a pooled effect size for each domain (i.e., behavioral outcomes, overall improvement, back pain–specific and generic functional status, return to work, and pain intensity) using the random effects model. Results. Only six (25%) studies were high quality. There is strong evidence (level 1) that behavioral treatment has a moderate positive effect on pain intensity (pooled effect size 0.62; 95% confidence interval [CI] 0.25, 0.98), and small positive effects on generic functional status (pooled effect size 0.35; 95% CI: −0.04, 0.74) and behavioral outcomes (pooled effect size 0.40; 95% CI: 0.10, 0.70) of patients with chronic low back pain when compared with waiting-list controls or no treatment. There is moderate evidence (level 2) that a addition of behavioral component to a usual treatment program for chronic low backpain has no positive short-term effect on generic functional status (pooled effect size 0.31; 95% CI: −0.01, 0.64), pain intensity (pooled effect size 0.03; 95% CI:−0.30, 0.36), and behavioral outcomes (pooled effect size 0.19; 95% CI: −0.08, 0.45). Conclusions. Behavioral treatment seems to be an effective treatment for patients with chronic low back pain,but it is still unknown what type of patients benefit most from what type of behavioral treatment.
Article
Low back pain is a major medical and social problem associated with disability, work absenteeism and high costs. Given the impact of the problem, there is a need for effective treatment interventions in occupational healthcare that aim at the prevention of chronic disability and the realisation of return to work. These so-called return-to-work (RTW)interventions are becoming increasingly popular. As well as questions concerning the effectiveness of RTW interventions, there are also important questions on the actual content and underlying concepts of these multifactorial intervention strategies. The purpose of this review is to examine the literature on the content and underlying concepts of RTW interventions for low back pain. Asystematic literature search identified 14 randomised controlled trials (RCTs) evaluating the effects of 19 RTW interventions. The content and concepts of these RTW interventions are described, compared and discussed in this review. Further, the contents of the RTW interventions are classified by the use of predefined components (physical exercises, education, behavioural treatments and ergonomic measures). The identified RTW interventions varied with respect to the disciplines involved, the target population and the number and duration of sessions. The classification showed that physical exercises were a component of most of the selected interventions, followed by education, behavioural treatments and ergonomic measures. The most prevalent combination of components was the combination of physical exercises, behavioural treatment and education. However, the types of physical exercises, behavioural treatment and education varied widely among the RTW interventions. Finally, the plausibility of the described concepts is discussed. Future RCTs on this topic should evaluate the underlying concepts of the RTW intervention in addition to its effectiveness.
Article
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% Cl, 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
Several treatment principles for the reduction of chronic low back pain associated disability have been postulated. To examine whether a combination of a physical training and an operant-behavioral graded activity with problem solving training is more effec-tive than either alone in the long-term, a cluster randomized controlled trial was conducted. In total 172 patients, 18–65 years of age, with chronic disabling non-specific low back pain referred for rehabilitation treatment, were randomized in clusters of four consec-utive patients to 10 weeks of aerobic training and muscle strengthening of back extensors (active physical treatment; APT), 10 weeks of gradual assumption of patient relevant activities based on operant-behavioral principles and problem solving training (graded activity plus problem solving training; GAP), or APT combined with GAP (combination treatment; CT). The primary outcome was the Roland Disability Questionnaire adjusted for centre of treatment, cluster, and baseline scores. Secondary outcomes were patients' main complaints, pain intensity, self-perceived improvement, depression and six physical performance tasks. During the one-year follow-up, there were no significant differences between each single treatment and the combination treatment on the pri-mary outcome, the Roland Disability Questionnaire. Among multiple other comparisons, only one significant difference emerged, with GAP and APT showing higher self-perceived improvement than CT. We conclude that the combination treatment integrating physical, graded activity with problem solving training is not a better treatment option for patients with chronic low back pain.
Article
Background: Behavioural treatment is commonly used in the management of chronic low-back pain (CLBP) to reduce disability through modification of maladaptive pain behaviours and cognitive processes. Three behavioural approaches are generally distinguished: operant, cognitive, and respondent; but are often combined as a treatment package. Objectives: To determine the effects of behavioural therapy for CLBP and the most effective behavioural approach. Search strategy: The Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, and PsycINFO were searched up to February 2009. Reference lists and citations of identified trials and relevant systematic reviews were screened. Selection criteria: Randomised trials on behavioural treatments for non-specific CLBP were included. Data collection and analysis: Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach. Main results: We included 30 randomised trials (3438 participants) in this review, up 11 from the previous version. Fourteen trials (47%) had low risk of bias. For most comparisons, there was only low or very low quality evidence to support the results. There was moderate quality evidence that:i) operant therapy was more effective than waiting list (SMD -0.43; 95%CI -0.75 to -0.11) for short-term pain relief;ii) little or no difference exists between operant, cognitive, or combined behavioural therapy for short- to intermediate-term pain relief;iii) behavioural treatment was more effective than usual care for short-term pain relief (MD -5.18; 95%CI -9.79 to -0.57), but there were no differences in the intermediate- to long-term, or on functional status;iv) there was little or no difference between behavioural treatment and group exercise for pain relief or depressive symptoms over the intermediate- to long-term;v) adding behavioural therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone. Authors' conclusions: For patients with CLBP, there is moderate quality evidence that in the short-term, operant therapy is more effective than waiting list and behavioural therapy is more effective than usual care for pain relief, but no specific type of behavioural therapy is more effective than another. In the intermediate- to long-term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. Further research is likely to have an important impact on our confidence in the estimates of effect and may change the estimates.