Bed rest for acute simple lower back pain

Report By: Simon Carley - Consultant in Emergency Medicine
Search checked by Johannes Willem Kleynhans - Clinical Fellow in Evidence Based Emergency Medicine
Institution: Manchester Royal Infirmary
Date Submitted: 23rd February 2005
Last Modified: 5th July 2005
Status: Orange (submitted and checked)

Three Part Question

[In patients presenting with acute lower back pain] is [bed rest better than active mobilisation and exercise] at [reducing pain, increasing mobility and speeding a return to normal physical activities]

Clinical Scenario

A 24 year old man presents to the emergency department with lower back pain sustained whilst lifting a heavy box the day before. He is in considerable pain when mobilising but this does improve with analgesia. There are no radicular signs nor evidence of a central disc lesion. He is normally fit and well. You diagnose a simple musculoskeletal back strain and advise him to mobilise and remain as active as possible. He tells you that "you must be joking, I'm going to bed until it gets better". You wonder how hard you should stress the need to remain active.

Search Strategy

Medline, CinAhl, AMED via the OVID interface on Athens. 1966- February 2005
Cochrane 2005 Issue 1
Medline, CinAhl, AMED
back pain.mp. or exp Back Pain/ or exp Low Back Pain/ or lumbar pain.mp. or exp Back Pain/ and exp EXERCISE THERAPY/ or exp EXERCISE/ and bed rest.mp. or exp Bed Rest/ or rest.mp
Cochrane
bed-rest

Search Outcome

Medline 66 citations including one recent systematic review. No new papers published after the Systematic review.
Cochrane 79 citations including the same systematic review found in Medline.
AMED. 15 citations. no new papers found.
CinAhl. 22 citations. none relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hagen KB 2003 UNK	Systematic review of papers comparing advice to stay in bed with more active therapies. Any controlled clinical, randomised or quasi randomised trials were eligible for the review. Studies had to recommend at least 2 days bed rest to be leigible. Only adults included.	Systematic review	Number of studies identified	11 studies identified. 5 included patients with neurological signs (sciatica).	Data is only extrapolated from 2 papers of "moderate risk of bias". These 2 studies have a total of 400 patients in them. Difficult to isolate the effect of bed rest in many studies which also include other modalities. One study suggested avoiding bed rest for 12 of 24 hours as the intervention.
			Quality of studies	6 were at low risk of bias, 2 were moderate risk , 3 were high risk.
			Pain intensity in simple low back pain at 3-4 weeks	based on 2 papers. Standardised mean difference of 0.22 (0.02-0.41)in favour of staying active
			Simple low back pain at 12 weeks	2 papers. SMD 0.25 (0.05-0.45)in favour of staying active
			Simple low back pain. Functional status at 3-4 weeks	SMD of 0.29 (0.09-0.49) in favour of staying active
			Simple low back pain. Functional status at 12 weeks	SMD of 0.24 (0.04-0.44) in favour of staying active
			Length of sick leave at 3-4 weeks	Weighted Mean Difference 3.4 days (1.64-5.16) in favour of staying active
			Length of sick leave at 12 weeks	4.5 days (1.37-7.63) in favour of staying active

Comment(s)

Acute simple lower back pain is a common presentation in then emergency department and in primary care. For most patients a good history and examination will exclude serious causes of back pain and the patient is then typically given advice on how to get better. The systematic review and meta-analysis found in this BET suggests on the basis of 2 trials that patients are likely to have less pain and better function at 3-4 and 12 weeks if they are advised to remain active rather than to rest in bed for 2 or more days. What is not know is if the patients in the mobilisation group suffer much more pain in the early stages. If so this is a potential harm in the active group. Neither study can answer this question, but we must remember to supply adequate analgesia if mobilisation is to be advocated.

Clinical Bottom Line

Patients with acute simple low back pain should be advised to remain active and not to rest in bed.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. The Cochrane Database of Systematic Reviews 2004 Issue 3Art. No.: CD001254. DOI: 10.1002/14651858.CD001254.pub2