I thought it was timely to revisit the literature on the management of acute low back pain (ALBP). In particular, I was interested in the current recommendations on the use of bedrest in the early stages of this condition. I recently treated a patient who had been admitted to a leading Sydney public hospital, and been placed on 2 weeks of strict bedrest. I have also found quite a degree of variability on what ALBP sufferers have been advised with regard to rest versus activity. It has always been my advice to patients to remain active (by walking), and to use bedrest only if pain makes this necessary. And even then, one to two days should be the maximum needed. So I was interested to see what the published recommendations were. In particular, what is recommended when the ALBP includes sciatica?
ALBP
Prior to the 1980’s, recommendations were varied and confusing. Many practitioners ordered strict and even lengthy bedrest, and admissions to hospital for bed-based traction was a regular practice. The problem of course, was the rapid and significant deconditioning that this caused. It is known, for instance, that there is a 10% reduction in bone mineral density with only 14 days in bed (8). Not only this, but many experts were of the opinion that healing of the injured back was delayed due to this practice. In 1986 a landmark paper was published, releasing the finding that no more than two days of bedrest should be recommended for patients with ALBP (3). This paper was then regularly quoted in musculoskeletal medicine and manual therapy, and a study half-a-decade later backed-up these recommendations (8). However it wasn’t long before clinicians started asking whether advice to stay active, with minimal or no bedrest, might be better still. Subsequent research has shown that remaining active is preferable, with even 1-2 days of bedrest potentially delaying recovery (1,2,5,6,7,9). Continued activity is likely to ensure faster return to work, less disability, and fewer recurrent problems (2,9), If required, bedrest should be seen as an undesirable consequence of, and not a management for, ALBP (9).
ALBP & Sciatica
A few studies have investigated whether bedrest should be recommended for patients with radicular pain in addition to their LBP. These patients are obviously much more challenging to manage, and as care-givers we prioritize pain-relief due to the severe discomfort suffered. While being upright can be very painful, and may exacerbate symptoms quickly, unfortunately there is no evidence that bedrest will either improve overall symptoms or speed-up recovery (1,2,4,5,6,9).
Problems with short-term bedrest
In my opinion, avoiding bedrest where possible is better for the following reasons:
1. When patients are in acute pain, getting out of bed can be extremely painful and very difficult. The less often they have to do this over the course of the day, the better. This degree of pain often results in extreme fear in many patients. It’s not unusual for an ambulance to be called in such cases, and unfortunately public hospitals are a very inappropriate place for such patients to be managed. A study showed that greater than 75% of emergency care physicians advised bedrest for ALBP (4).
2. Cartilage and intervertebral discs receive much better nutrition from the even and gently variable loading received with upright walking. In addition, activity helps to maintain bone and muscle strength. Walking may also raise endorphin levels (4).
3. When present, disc bulges are dynamic, and respond to load by changing position and size. While lying down can be painless, the eventual necessary movement of rolling over or getting up will place sudden load on the displaced area of the disc. Upright loading is the type most likely to promote anatomical positioning of the bulging disc segment, and ultimately to help it to return towards normal.
4. Proteoglycans within the disc nucleus draw in water when we lay down, increasing intradiscal pressure. This a common reason why acute pain will be a lot worse on initially rising after laying down.
References:
1. Atlas, S & Deyo, R (2001). Evaluating and managing acute low back pain in the primary care setting. Journal of General Internal Medicine, 16, 2, 120-131.
2. Dalm, K et al (2010). Advice to rest in bed versus advice to stay active for acute low back pain and sciatica. Cochrane Database Systematic Review, 16, 6, CD007612.
3. Deyo, R et al (1986). How many days of bedrest for acute low back pain? A randomized clinical trial. New England Journal of Medicine, 315, 17, 1065-1070.
4. Elam, K et al (1995). How emergency physicians approach low back pain: choosing costly options. Journal of Emergency Medicine, 13, 2, 143-150.
5. Hagen, K et al (2003). The updated Cochrane Review of bedrest for low back pain and sciatica. Spine, 30, 5, 542-546.
6. Kinkade, S (2007). Evaluation and management of acute low back pain. American Family Physician, 75, 8, 1181-1188.
7. Malmivaara, A et al (1995). The treatment of acute low back pain – bedrest, exercises or ordinary activity? New England Journal of Medicine, 332, 6, 351-355.
8. Szpalski, M & Hayez, J (1992). How many days of bedrest for acute low back pain? Objective assessment of trunk function. European Spine Journal, 1, 1, 29-31.
9. Waddell, G et al (1997). Systematic reviews of bedrest and advice to stay active for acute low back pain. British Journal of General Practice, 47, 423, 647-652.
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