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A cluster-randomized controlled trial.To evaluate the effects of two strategies to increase the use of active sick leave (ASL) among patients with low back pain (LBP) on improved return to work and quality of life.Active sick leave is an option provided by the Norwegian National Insurance Administration that enables employees to return to modified duties at the workplace with 100% of normal wages. A proactive implementation strategy increased the use of ASL for LBP patients from 11.5% to 17.7% compared with a passive intervention and a control group (P = 0.006).Sixty-five municipalities were randomly assigned to a passive intervention, a proactive intervention, or a control group. The interventions, which were designed to improve the use of ASL, were targeted at patients on sick leave for LBP for more than 16 days (n = 6179), their general practitioners, employers, and local insurance officers. The main outcome measures were the average number of days off work, the proportion of patients returning to work within 1 year, and self-reported quality of life while on sick leave.The median number of days on sick leave was similar in the proactive intervention group (70 days), the passive intervention group (68 days), and the control group (71 days) (P = 0.8). The proportion of patients returning to work before 50 weeks was also similar in the proactive (89%), passive (89.5%), and control groups (89.1%). Response rates for the questionnaires that were sent to patients were low (38%), and no significant differences were observed across the three groups for quality of life or patient satisfaction.It is not likely that efforts to increase the use of ASL will result in measurable economic benefits or improved health outcomes at the population level. The benefits of ASL for individual patients with LBP are not known.