An updated review now confirms what has become conventional wisdom: “Normal daily activity seems to be the best way for patients with low-back pain to get better,” said Kristin Thuve Dahm, a researcher at the Norwegian Centre for the Health Services and lead author of the review.
Active patients experience less pain and avoid the side effects of immobility.
The review appears in the latest issue of The Cochrane Library, a publication of the Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
In the review, which directly compared rest in bed and staying active, the authors combined two previous Cochrane reviews, published in 2002 and 2004, that evaluated the two treatments separately. They also searched for additional recent randomized trials, but found none.
The fact that no new study has been published in nearly 10 years “shows that research done in the past already proved the point. Everyone is fairly convinced there’s not much benefit to bed rest,” said Joel Press, M.D., professor in physical medicine and rehabilitation at the Feinberg Northwestern School of Medicine in Chicago.
The researchers looked at two kinds of low back pain: with and without sciatica.
Although the term “sciatica” is often applied to low-back pain in which pain radiates down one or both legs, reviewed studies defined it more strictly: low-back pain accompanied by signs of nerve compression or damage, like numbness, tingling or weakness in the leg.
The comparison between bed rest and normal activity for low-back pain without sciatica used data from three studies that included 481 patients. All three found improvements in pain intensity with both treatments, with no significant differences between them.
One of the studies, however, involved a highly specific group of patients — 80 young combat trainees who were hospitalized for their back pain — “and thus, it’s applicability to the general population is questionable,” the authors wrote.
When the reviews pooled data from the other two studies, patients who stayed active experienced reductions in pain that were more significant, although the difference was “of limited clinical importance,” they wrote. The difference in pain persisted at follow-up 12 weeks later.
The same two studies found significantly greater improvements in the ability to function in the group that stayed active, four weeks and 12 weeks after treatment.
In comparing treatments for sciatica, the reviewers analyzed data from two studies of 348 patients. No difference existed in pain intensity, directly after treatment or 12 weeks later, between sciatica patients who received advice to stay active and those whose doctors prescribed bed rest. Similarly, there was no difference between groups in patients’ ability to function.
“The available evidence neither supports nor refutes that advice to stay active is better than resting in bed for people with sciatica,” Dahm said. “However, considering that bed rest is associated with potential harmful side effects, we think it is reasonable to advise people with sciatica to stay active.”
In general, Press said, “we’re almost always better moving than not moving. Structures in your back get their nutrition from movement; they have no real vascular system and are supplied with blood by motion, soaking it up like little sponges.”
Negative changes associated with immobility “manifest right away,” he said. Studies done in the 1950s showed that people lose 2 percent to 5 percent of their strength per day of complete bed rest.
The reviewers also compared bed rest and activity with other treatments. Pooled data of three studies including 931 low-back pain patients found little or no difference in pain or ability to function between patients on bed rest and those prescribed exercises.
Similarly, results of a single trial with 186 patients suggested that “exercises add no clinically relevant benefit for patients with acute low-back pain when compared to advice to stay active,” the authors wrote.
They came to the same conclusion about physiotherapy compared to either bed rest or activity for sciatica, from a single study involving 167 patients.
Press emphasized the need for future research to categorize back pain more precisely. “Not all back pain is the same; there are lots of different causes,” and the chances of finding a single treatment to benefit all patients are not good, he said. The goal should be defining subgroups “so we can predict from symptoms, physical examination and imaging studies which patients will respond to which types of treatment.”
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The Cochrane Library (http://www.thecochranelibrary.com) contains high quality health care information, including Systematic Reviews from The Cochrane Collaboration. These reviews bring together research on the effects of health care and are considered the gold standard for determining the relative effectiveness of different interventions. The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.
Dahm KT, et al. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. The Cochrane Database of Systematic Reviews 2010, Issue 6.