Reason for withdrawal from publication
May 11th, 2010
This review has been merged with:Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews 2000 , Issue 2 . Art. No.: CD001254. DOI: 10.1002/14651858.CD001254.pub2. to form new review: Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database of Systematic Reviews 2010 , Issue 6 . Art. No.: CD007612. DOI: 10.1002/14651858.CD007612 .
Feb 3/06 - contact author notified that review will be withdrawn in the submission this month since last lit search was in 1998. Updated review will be published once submitted and approved. VEP
Cochrane Review: Advice to stay active for low back pain and sciatica
A Commentary by the Editorial Board of the Cochrane Back Review Group.
This is a methodologically sound review that has produced what to many readers will appear to be a surprising conclusion. Although the authors qualify it in the detail of the text, the main message that comes across is that there is no scientific evidence or significant clinical benefit for patients with back pain to stay active! This is contrary to all other systematic reviews (Abenhaim et al 2000, Nachemson & Jonsson 2000, Waddell & Burton 2000) and international clinical guidelines (Koes et al 2001) which state there is strong evidence that patients with acute LBP should be advised to avoid bed rest if possible (certainly for more than a few days), to stay active, and to get on with their ordinary activities as normally as possible.
The reason appears to be methodological. This review focuses very specifically on RCTs where one group had advice to stay active as a single treatment with no co-interventions. That review design originally appeared logical and reasonable and was approved by the editorial group of the Back Review Group, but it has had unforeseen consequences. In clinical practice and scientific trials, it is unusual to offer such advice in isolation without any other symptomatic or supportive measures, so it is understandable that criteria has included a very limited group of four, highly selected and heterogeneous RCTs in the review. Only one of the four trials (Malmivaara 1995) was a balanced study of three interventions, one of which was specific 'advice to stay active' - to 'continue their routines as actively as possible within the limits permitted by their back pain' - and that was the most effective intervention. The other three RCTs were actually trials of bed rest and the control groups were given various alternative instructions contrary to bed rest. Wiesel (1980) used an unrepresentative group of army recruits in an army setting (which is the only RCT in favour of bed rest compared with remaining ambulatory): that control group was 'assigned a restricted-duty status that eliminated all physical exercise'. The control group in Wilkinson (1995) were simply 'encouraged to keep mobile and to have no daytime rest'. Vroomen (1999) was a trial of acute disc prolapse and the control group consisted of 'watchful waiting' with 'instructions to be up and about whenever possible but to avoid straining the back or provoking pain'. With these very different interventions, it is hardly surprising this review of four RCTs did not show any clear effect of 'advice to stay active'.
This illustrates the tension frequently encountered in Cochrane reviews between lumping or splitting of the available evidence: broad inclusion criteria may lump together trials that are too heterogeneous while narrow inclusion criteria, as in this review, result in an incomplete analysis of the available evidence. Putting the four trials included in this review into the broader available evidence about rest or staying active produces very different conclusions.
The Cochrane Review of bed rest for acute back pain (Hagen et al 2000) included 9 RCTs which showed unanimously (with the exception of Wiesel) that bed rest was ineffective. That review concluded there was strong evidence against bed rest and indeed is the only Cochrane review in this field to state that the evidence is now so strong there is no need for any further studies. If there is such strong evidence against bed rest, the corollary is that patients should stay active instead.
The exclusion of any trials with co-interventions also discounts the large number of RCTs which show that multi-disciplinary interventions are effective in sub-acute LBP (Waddell et al 1997). A key element of these packages is progressive increased activity and rehabilitation (Abenhaim et al 2000, Nachemson & Jonsson 2000, Waddell & Burton 2000). It ignores the evidence on the effectiveness of exercise for chronic LBP (van Tulder et al 2000). It ignores recent evidence on innovative educational approaches based on advice to stay active and get on with normal life (Burton et al 1999, Moore et al 2000, Buchbinder et al 2001).
There are a number of areas where the evidence is unclear and further research is required. There is lack of conceptual clarity between avoiding bed rest, positive advice to stay active and simply letting patients get on with normal life. There is lack of evidence on the exact nature and form of advice that is most effective. What is the relation between advice, information and education? How should advice to stay active be combined with symptomatic measures and what is the best package of interventions? How does advice to stay active relate to work? That all needs to be set in the context of the entire time course from acute to subacute to chronic low back pain and disability. Clinical management must be integrated with occupational health management.
Most important, however, this Cochrane review should not undermine current teaching. The best scientific evidence available at present, and all evidence-based guidelines agree, is that patients with acute LBP should be advised to avoid bed rest if possible (certainly for more than a few days), to stay active, and to get on with their ordinary activities as normally as possible.
Cochrane Review multidisciplinary rehabilitation
*Abenhaim L, Rossignol M, Valat J-P, et al. The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain. Spine 2000; 25: Suppl. 4S: 1S-33S.
*Buchinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: three part evaluation. Brit Med J 2001; 322:1516-1520.
*Burton, A. K., Waddell, G., Tillotson, K. M., & Summerton, N. Information and advice to patients with back pain can have a positive effect: a randomized controlled trial of a novel educational booklet in primary care, Spine 1999; 24: 2484-2491.
* Hagen, K.B., Hilde, G., Jamtvedt, G., Winnem, M.F. The Cochrane review of bed rest for acute low back pain and sciatica. Spine 2000;25(22):2932-2939.
*Koes, B. W., van Tulder, M. W., Ostelo, R., Burton, A. K., & Waddell, G. 2001, Clinical guidelines for the management of low back pain in primary care: an international comparison, Spine 2001; (in press).
*Malmivaara A, Häkkinen U, Aro T, et al.. The treatment of acute low back pain: bed rest, exercises, or ordinary activity? N Engl J Med 1995;332:351-5.
*Moore J E, Con Korff M, Cherkin D, Saunders K, Lorig K A randomized trial of a cognitive-behavioral program for enhancing back pain self care in a primary care setting. Pain 2000;88:145-153
*Nachemson A, Jonsson E, (Eds). Neck and back pain: the scientific evidence of causes, diagnosis and treatment. Philadelphia: Lippincott, Williams & Wilkins 2000. ISBN 0 7817 2760 X
*Tulder, MW Van, Malmivaara, A., Esmail, R., Koes, B. Exercise therapy for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000; 25(21)2784-2796.
*Vroomen P C A F, De Krom M C T F M, Wilmink J T, Kester A D M, Knottnerus J A Lack of effectiveness of bed rest for sciatica. New Eng J Med 1999;340:418-423
*Waddell, G. & Burton, A. K. Occupational health guidelines for the management of low back pain at work - Evidence review Faculty of Occupational Medicine, London. 2000, www.facoccmed.ac.uk
*Waddell, G., Feder, G., & Lewis, M. Systematic reviews of bed rest and advice to stay active for acute low back pain, British Journal of General Practice 1997; 47: 647-652.
*Wiesel S W, Cuckler J M, Deluca F, Jones F, Zeide M S, Rothman R H Acute low back pain. An objective analysis of conservative therapy. Spine 1980;5:324-330
*Wilkinson M J B Does 48 hours bed rest influence the outcome of acute low back pain? British Journal of General Practice 1995;45:481-484