Thursday, June 24, 2010

Is Staying Active Best for Acute Low-Back Pain?

Back PainAccording to an updated Cochrane Review, continuing normal daily activity rather than bed rest seems to be the best advice for patients with acute low-back pain. However, it appears from the evidence that it is unreasonable to expect that staying active will actually hasten recovery.

At one time, “rest”— meaning a few days to a week in bed — was the standard prescription for acute low-back pain. More recently, healthcare providers have been counseling patients to stay as active as they can. In an updated systematic review for the Cochrane Collaboration, investigators conducted an exhaustive literature search up to May 2009 for studies evaluating the effects of advice either to rest in bed or to stay active on individuals with acute low-back pain (<6 weeks duration) with or without sciatica [Dahm et al. 2010]. Although the term “sciatica” is often broadly applied to low-back disorders in which pain radiates down one or both legs, the reviewed studies defined it as low-back pain accompanied by signs of nerve compression or damage, like numbness, tingling, or weakness in the leg.

The search discovered 10 randomized clinical trials of relevance (N = 1,923 subjects). Although the evidence is of low to moderate quality overall, results indicate that patients with acute low-back pain may experience small improvements in pain relief and ability to perform everyday activities (functional status) if they receive advice to stay active compared with advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches. Furthermore, it appears doubtful whether other treatment strategies — eg, physiotherapy, manipulation, or exercise programs — confer any greater benefits for acute pain than merely staying generally active.

None of the included studies reported significant negative side effects of bed rest; however, Dahm and colleagues note that adverse physiological effects (eg, loss of strength) have been previously reported. Therefore, while available evidence neither supports nor refutes that advice to stay active is of clinically significant benefit, the authors suggest that continuing normal daily activities is preferable to bed rest for acute low-back pain with or without sciatica.

COMMENTARY: Interestingly, the investigators found that no new studies had been published on this topic in nearly 10 years, so they combined two previous Cochrane reviews published in 2002 and 2004 that had separately evaluated either bed rest or staying active. Limitations of available evidence precluded a meta-analysis of the data, so we agree with the authors that further research would be helpful in determining which patients might benefit most from activity and if there are specific physical or other therapies that might hasten recovery from acute low-back pain. For example, our previous research/writings on vitamin D supplementation suggest that this could be of benefit for nonspecific low-back pain in many patients [see blogpost list here and research documents here].

Finally, lower-back pain, with or without sciatica, seems to be a rather broad diagnostic category. The authors of this review did exclude trials pertaining to patients with chronic pain (>6 weeks), inflammatory joint diseases, infections, neoplasms, metastases, osteoporosis, or fractures. However, it is unclear whether patients with pain due to traumatic injury or specific pathology (eg, ruptured or herniated disks) also had been excluded. Therefore, one might recommend the general advice “stay active” as applying most appropriately to patients in whom a precipitating medical cause is undetermined and in accordance with accepted guidelines [for example, see Bach et al. 2009 and ICSI 2008].

> Bach SM, Holten KB. Guideline Update: What’s the Best Approach to Acute Low Back Pain. J Fam Pract. 2009;58(12):E11 [
article here].
> Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Sys Rev. 2010(Jun 16);6(No. CD007612) [
abstract here].
> ICSI (Institute for Clinical Systems Improvement). Adult Low Back Pain. 2008 [
PDF document here].