Sports Medicine Approach to Low Back Pain

Mathew W. Lively, DO

South Med J. 2002;95(6) 

In This Article

Bed Rest or Early Activity?

Despite little supporting scientific evidence, bed rest was considered the primary treatment for LBP and sciatica from the late 19th century up to modern times.[9] Although some authors during this time did question the use of bed rest,[11] it was not until the 1980s that its efficacy as a treatment for LBP began to be seriously questioned.[12] In fact, so prevalent was the assumption that some rest was necessary, initial studies only questioned the amount of bed rest that was needed. The foremost article investigating the use of bed rest in LBP was that of Deyo et al[13] in 1986 that compared 7 days of rest to 2 days. They found no difference in functional status or symptoms between the 2 groups. Their article is the basis for several current guidelines that advise no more than 2 days of rest for patients with acute LBP. Other studies have since shown that bed rest of any duration is not an effective therapy for LBP and that it often delays recovery.[2,14,15,16] Sciatica, even when due to nerve-root compression, is not improved with bed rest either.[17] Detrimental results of prolonged bed rest include losses in muscle protein and bone calcium, lumbar muscle atrophy, and undesirable psychologic effects.[18,19] Despite the evidence against bed rest as a treatment for LBP, many physicians continue to advise its use. In a 1995 survey,[20] 72% of physicians thought that strict bed rest for more than 3 days was an effective treatment for acute LBP.

Although bed rest has been shown to be ineffective and detrimental in the treatment of LBP, is early activity any better? Several studies have looked at the effects of early return to daily activities[21,22,23,24] and progressive exercise programs[25,26,27,28,29] in the treatment of LBP. One of the best-controlled studies was that of Malmivaara et al in 1995.[23] The authors randomly assigned patients with acute, nonspecific LBP to 1 of 3 treatment groups: (1) bed rest for 2 days; (2) back-mobilizing exercises; or (3) continuation of ordinary activities. At 3-week and 12-week follow-up evaluations, the individuals assigned to ordinary activity had significantly less pain, fewer days absent from work, and less disability than the other 2 groups. Those assigned to bed rest had the slowest recovery. A similar British study[24] produced the same results.

The evidence supporting the use of specific back exercises (eg, flexion and extension) for acute pain is not encouraging.[23,30,31,32] The majority of studies show that specific exercises for LBP are no more beneficial than other conventional treatments for acute pain. The exercise techniques used in these studies, however, were often not appropriately applied to the specific condition or symptom for which they are commonly used. Despite these methodologic problems, most systematic reviews[16,33] and clinical practice guidelines[14,34,35] do not recommend specific back exercises for acute pain.

For chronic LBP, good evidence supports exercise therapy over "usual care" (ie, rest, medications, modalities) by a physician in terms of return to work and functional status.[28,29,33] Individuals with chronic back pain who are prescribed graded increases in activity levels also return to work sooner, have less disability, and have fewer pain complaints than traditionally treated patients.[21,25,26,27,28,29]

Low back pain in the clinical setting is often an episodic and recurrent condition that plagues individuals throughout their lives; therefore, secondary prevention measures that limit the number and duration of exacerbations are particularly important. Early activity and exercise, once again, seem to be the key to successful management of recurrent LBP. In those studies utilizing early return to activity as therapy for acute LBP, individuals with 1 year of follow-up after treatment reported less chronic disability, sick leave, and pain than those assigned bed rest or other traditional treatment.[21,28,29,36] Individuals who remain active and physically fit also have fewer recurrences of LBP, and their attacks are shorter in duration.[16,32,37,38,39]

The medical evidence in favor of early, progressive activity and avoidance of bed rest for the management of LBP is substantial and serves as the foundation for the sports medicine approach to treatment.

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