For Acute Low Back Pain, Staying Active May Be Better Than Bed Rest

From Medscape Medical News

Laurie Barclay, MD

June 30, 2010 — Advice to stay active vs bed rest may offer small benefits in pain and function for patients with acute low back pain (LBP), but both approaches are comparable for patients with sciatica, according to the results of a review reported online June 16 in the Cochrane Database of Systematic Reviews.

"Acute...LBP is a common reason to consult a general practitioner," write Kristin Thuve Dahm, from the Norwegian Knowledge Centre for the Health Services in Oslo, Norway, and colleagues. "Debate continues on the comparative effectiveness of advice on bed rest and staying active as part of the primary care management."

To evaluate the outcomes of advice to rest in bed or to stay active for patients with acute LBP or sciatica, the reviewers searched the Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, Sport, and SCISEARCH to May 2009. They also searched bibliographies of pertinent articles and contacted study authors.

Criteria for inclusion in the review were randomized controlled trials of the efficacy of advice to stay active or rest in bed for patients with acute LBP or sciatica, with primary study endpoints of pain, functional status, recovery, and return to work. Two reviewers independently extracted data and determined the risk for bias for selected studies, which were combined qualitatively or statistically, as appropriate on the basis of data availability and presentation.

The 10 selected randomized controlled trials had varying risk for bias. Findings from 2 trials enrolling a total of 401 patients with acute LBP suggested that advice to stay active was associated with small improvements in pain relief (SMD, 0.22; 95% confidence interval [CI], 0.02 - 0.41) and in functional status (SMD, 0.29; 95% CI, 0.09 - 0.49). There was moderate-quality evidence that patients with sciatica who were given advice to rest in bed or to stay active had little or no difference in pain relief (standardized mean difference [SMD], –0.03; 95% CI, –0.24 to 0.18) or in functional status (SMD, 0.19; 95% CI, –0.02 to 0.41).

For patients with acute LBP, low-quality evidence from 3 randomized controlled trials enrolling a total of 931 patients suggested little or no difference among exercises, advice to rest in bed, or to stay active. For patients with sciatica, low-quality evidence from 1 randomized controlled trial enrolling a total of 250 patients suggested little or no difference among physiotherapy, advice to rest in bed, or to stay active.

Various strategies for advising patients were not compared in any of the identified trials.

Limitations of this review include those inherent in the included studies, with varying quality of evidence and risk for bias.

"Moderate quality evidence shows that patients with acute LBP may experience small benefits in pain relief and functional improvement from advice to stay active compared to advice to rest in bed; patients with sciatica experience little or no difference between the two approaches," the study authors write.
"Low quality evidence suggests little or no difference between those who received advice to stay active, exercises or physiotherapy. Further research is very likely to have an important impact on the estimate of effect and is likely to change our confidence in it."

The review authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online June 16, 2010. Abstract