Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica

Low-back pain (LBP) is one of the most common conditions managed in primary care and a significant cause of absence from work and early retirement. Individuals, their families and society at large all carry part of the burden.

Many people get some relief from low-back pain and sciatica (pain down the back and leg) by lying down. Until the late 1990s, advice to 'take it easy' and 'rest' was a common treatment approach. The exact nature of the 'rest' varied, but often it meant staying in bed full time, only taking trips to the bathroom and sometimes the kitchen.  

However, as the millennium dawned, it became evident that extended periods of bed rest were potentially harmful because they may lead to the deterioration of muscles and body functions.

This review is the result of the combination of two previous reviews: Bed rest for acute low-back pain and sciatica and Advice to stay active as a single treatment for low-back pain and sciatica and an update of the literature search.  No new randomised trials were identified.

This blended, updated review included 10 randomised trials (N = 1923). It evaluated the effects of advice to rest in bed or stay active on individuals with acute low-back pain (pain lasting for less than 6 weeks) with or without sciatica.

Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed.  However, patients with sciatica experience little or no difference between the two approaches.  Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality evidence suggests those patients with or without sciatica experienced little or no difference in pain relief or function, regardless of whether they 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.

Authors' conclusions: 

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. 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.

Read the full abstract...
Background: 

Acute low-back pain (LBP) is a common reason to consult a general practitioner. Debate continues on the comparative effectiveness of advice on bed rest and staying active as part of the primary care management.

Objectives: 

To determine the effects of advice to rest in bed or stay active for patients with acute low-back pain or sciatica.

Search strategy: 

We searched the Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, Sport, and SCISEARCH to May 2009, reference lists of relevant articles, and contacted authors of relevant articles.

Selection criteria: 

Randomised trials of the effectiveness of advice to stay active or rest in bed for patients with acute LBP or sciatica. The main outcomes were pain, functional status, recovery and return to work.

Data collection and analysis: 

Two authors independently selected trials, assessed the risk of bias and extracted data. The trials were combined qualitatively or statistically, depending on data availability and presentation.

Main results: 

We included ten RCTs with varying risk of bias. For patients with acute LBP, results from two trials (N = 401) suggest small improvements in pain relief (SMD 0.22 (95% CI: 0.02 to 0.41) and functional status (SMD 0.29 (95% CI: 0.09 to 0.49) in favour of advice to stay active. For patients with sciatica, there is moderate quality evidence of little or no difference in pain relief (SMD -0.03 (95% CI: -0.24 to 0.18)) or functional status (SMD 0.19 (95% CI: -0.02 to 0.41)), between advice to rest in bed or stay active.

Low quality evidence (3 RCTs, N = 931) suggests little or no difference between exercises, advice to rest in bed or stay active for patients with acute LBP. Low quality evidence (1 RCT, N = 250) suggests little or no difference between physiotherapy, advice to rest in bed or stay active for patients with sciatica. No trials that compared different ways of delivering advice.

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