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Table 2 Steps of the graded activity protocol

From: Multidisciplinary outpatient care program for patients with chronic low back pain: design of a randomized controlled trial and cost-effectiveness study [ISRCTN28478651]

Step Characteristics  
   The GA program starts within one week after the patient visits the care manager.
Before starting the baseline phase   -The PT performs a history-taking and a physical examination;
-The PT gives counseling using the bio-psycho-social model on the development and maintenance and the consequences of pain;
-The PT states that it is safe to start the GA program.
1 Baseline phase Pain Contingent
Patient may stop at any time if he feels pain or other discomfort
Individual training
3 sessions of 1.5 hour
- Baseline consists of 6 fixed and 3 free exercises (simulating work situation);
- Aim is to determine the maximal performance for each exercise separately;
- According to the results, a start quota (70% of the mean) and the load of each exercise session until the end of the program will be set;
- The load of each quota depends on the date of full RTW;
- When all quota are set, the PT will send the baseline results and the treatment report to the employee, the employer and the multidisciplinary team.
2 Treatment phase Time contingent
Pain is not a reason for stopping or altering the program
Group training twice a week
(4–6 persons)
1 hour per session
- The pre-set quota have to be followed strictly;
- The PT accompanies the treatment sessions and evaluates the sessions;
- A positive reinforcement will be given by the PT after completion of the quota;
- When the date of RTW is within a few weeks, the learned behaviour and management of pain will be discussed. At this point the frequency of the sessions will be decreased to once a week until the patient returns to work;
- When the employee fully returns to work or after 26 sessions the protocol will stop. A final communication form will be send to the multidisciplinary team.
   Every three weeks, the PT sends an evaluation form to the multidisciplinary team to report the progress of the treatment protocol.
   When the patient is sick listed because of LBP within 4 weeks after RTW, the GA program will be continued. It will again stop as soon as the patient fully returns to work, or all 26 sessions of the GA program are given.
  1. GA, graded activity; PT, physical therapist; RTW, return to work; LBP, low back pain.